How many attacks are there on health care facilities in Syria?
Dr. Rohini Haar, a public health researcher at the University of California, Berkeley, led a team that collected ground reports of attacks in 2016 in northern Syria, filed by civilians via cellphone text. Leonard Rubenstein at the Johns Hopkins University School of Public Health led the study.
Haar wanted to find out if human rights organizations were missing anything in their reports. Sending outside investigators into a country, or monitoring news reports and social media, certainly has merit, she thought. "But that doesn't capture all the stuff that goes on day to day that people don't realize is also a violation of international law," she says.
She was shocked by the relentlessness of the attacks.
The data, which appears Tuesday in the journal PLOS Medicine, shows a total of 200 health care-related attacks in the governorates of Aleppo, Idleb, Homs and Hama. Haar and her team focused on these provinces because they include large, historically rebel-held cities — Idleb and Aleppo — that had already sustained a lot of violence.
Over 2016 that averages out to more than one attack every other day, says Haar. In the attacks her team analyzed, 112 health-care staff and 185 patients died.
To compile the data, researchers partnered with the Syrian American Medical Society, which operates and funds many of the hospitals that have sustained attacks in northern Syria.
SAMS hired eight civilians to visit the scene of attacks once it was safe, interview survivors and witnesses and take photos. The information was sent back to SAMS offices in Gaziantep, Turkey, via text message or an app-based questionnaire. SAMS checked these details against other witnesses' reports.
Haar and her team found that the majority of attacks occurred via aerial bombing, so it was difficult to identify a perpetrator. These attacks from above nearly always damaged structures. As a result of the attacks, eight clinics and hospitals were permanently closed; 41 other health-care facilities closed temporarily.
Even when health facilities manage to survive these attacks, the threat to medical care remains, says Dr. Ahmad Albaik, a physician who works with SAMS to administer health care in Syria. Albaik is based in Gaziantep, Turkey.
Before Albaik worked on this study, he practiced medicine in Aleppo between 2013 and 2015. He saw the effects of these attacks firsthand: Patients begin to fear hospitals because of the risk of bombing during treatment, he says, and doctors would leave areas where clinics sustain attacks. "If they can't have a safe place to work to care for people's lives, and they are a target as well, they will leave," he says.
A previous effort to identify the number of attacks in northern Syria, by Physicians for Human Rights, used information from press reports and social media to tally and verify 90 attacks on health facilities in 2016.
PHR focuses strictly on attacks on health facilities and verifies incidents only after receiving two independent reports. With on-the-ground photos and reports from multiple witnesses, Haar's team could verify more attacks and could also tally attacks on patients, health workers and ambulances.
Although the new data exceeds other estimates of attacks on health care in northern Syria in 2016, Haar still thinks her results underestimate the total violence against medical facilities and workers. "There's probably a whole subset of incidents that everybody's missing," Haar says. SAMS data collectors were much more likely to report attacks on large hospitals than smaller, rural clinics.
"The fact that these numbers are no doubt a minimum is also shocking," says Susannah Sirkin, a senior adviser at Physicians for Human Rights.
Sirkin does not believe the health facilities are suffering collateral damage in general attacks. Because health facilities are often the largest buildings in rural areas of Syria and because hospitals have experienced repeated bombings, she believes they are being deliberately targeted — a violation of humanitarian law.
Haar agrees, noting that most hospitals in Syria no longer display the Red Cross or Red Crescent markings that brands them as medical facilities. "They've been removed because they're creating a giant target, literally," she says. Unfortunately, she says, the GPS coordinates of larger hospitals and clinics are already known, so they're still under threat.
Haar's data shows that 33 hospitals sustained more than one attack in 2016. Two hospitals in Aleppo city were attacked over 10 times. From such a barrage, Sirkin says, "you can infer complete intent to destroy access to health care for the the sick."
According to reports, the Syrian government and Russia, its ally, have denied targeting health facilities.
The violence of the civil war doesn't seem to be letting up. WHO has launched an effort to track attacks on health care facilities, personnel, and patients by combining data from nongovernmental organizations and U.N. agencies. So far, it counts 74 such attacks in Syria in 2018.
"There are no safe places," Albaik says.
Menaka Wilhelm is a freelance writer covering health and technology. She's on twitter: @menakawilhelm.