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Syrian Civil War Obliterates Principle of Hospitals as Safe Spaces

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In Aleppo, death rains down from the sky without mercy, as Syrian and Russian war planes repeatedly bomb hospitals and target medical personnel despite widespread condemnation of violating international humanitarian law.

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Photo: Karam Alamsri / MSF

Dr. Abu Wasim, a plastic surgeon, stands next to a damaged ward on the upper floors of a hospital in east Aleppo on Nov. 10, after it was hit by an air strike in mid-October 2016. At the time, he was one of seven surgeons left in the war-torn city.

Two remaining hospitals and the central blood bank in eastern Aleppo were bombed in November, the 13th attack on medical facilities across northern Syria in less than a week that killed more than 30 medical personnel and civilians, including children, the Syrian American Medical Society reported. There were 138 attacks on medical facilities since July, averaging one attack per day, by Syrian and Russian forces using missiles and cluster bombs. To a lesser extent, the rebel forces in Syria also have been accused of indiscriminate shelling, including the killing of two female medics at a Russian field hospital in Aleppo, according to the Russian government.

But it is Syrian President Bashar al-Assad who has been accused of deliberately targeting medical facilities and workers — through bombings, assassinations, detention and torture — to bring the city to its knees. Thousands of doctors used to operate in Aleppo, a once-vibrant commercial hub. Almost all of them have fled. According to the advocacy group Physicians for Human Rights, over 750 medical workers have died since the war began in March 2011, the bulk of them killed by the Syrian regime.

The targeting of medical facilities is not a new phenomenon. During the past three years, 2,400 attacks have targeted medical facilities, centers and convoys in 11 countries, according to the International Committee of the Red Cross. While Syria has dominated the headlines, hospitals also have been bombed, raided or burned in Yemen, Afghanistan, South Sudan, Ukraine and the Central African Republic.

But Physicians for Human Rights calls the scale of destruction in Syria “unparalleled,” and experts fear it has fueled a worrying trend on the battlefield.

Hospitals once were safe places in war zones, protected by the Geneva Conventions and other international laws, but the relentless bombing campaigns in Syria have violated those norms with apparent impunity. Condemnations from the United Nations and nongovernmental organizations have done little to stem the carnage, and there have been few investigations of war crimes, in part because of the dangerous and chaotic conditions in active battlegrounds.

In 2015, 75 medical facilities that were operated or supported by Doctors Without Borders (Médecins Sans Frontières) were attacked, and 63 of them were in Syria, said Jason Cone, executive director of the organization’s U.S. section.

“What we’ve seen over the past two years, it’s pretty horrific, specifically with what’s happening in Syria,” he told The Diplomat. “Health care has become part of the battlefield in Syria. Hospitals are very much part of the war strategy that Syria employs along with its allies, including Russia.”

Russia and China vetoed a U.N. Security Council draft resolution on Dec.5 that would have called for a weeklong ceasefire in Aleppo so humanitarian aid could be provided after Syrian forces had gained significant ground there through intense bombardment and troop movements. It was the sixth Russian veto and the fifth by China of resolutions relating to Syria since 2011. As of press time, the rebel-held portion of Aleppo had fallen to the regime, with major world powers haggling over how the remaining civilians should be evacuated.

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Photo: Karam Alamsri / MSF
A doctor stitches the ear of a man injured in air strikes on Bab Al Nayrab district in east Aleppo.

In May, U.N. Resolution 2286, which was co-sponsored by more than 80 member states, condemned attacks on medical personnel following the inadvertent U.S. bombing of a Doctors Without Borders facility in Afghanistan that killed 42 people.

U.N. Secretary-General Ban Ki-Moon decried the hospital attacks at the Security Council meeting in May. “When so-called surgical strikes are hitting surgical wards, something is deeply wrong,” he said. “Even wars have rules.” He said all member states “must use every ounce of influence to press parties to respect their obligations” under international law.

In a speech to the U.N. Security Council last September, Dr. Joanne Liu, international president of Doctors Without Borders, said the U.N. resolution “has plainly failed to produce any effect on the ground” in Syria because of a “lack of political will among member states fighting in coalitions and those who enable them.” She challenged the Security Council and member states to act following the destruction of the al-Quds hospital in Aleppo, attacks on humanitarian aid convoys in Syria and the destruction of a Doctors Without Borders hospital in Yemen in an air strike by the Saudi-led coalition that killed 19 patients and health workers. It was the fourth attack on the organization’s facilities in Yemen in less than a year.

“We denounce the deliberate and systemic failure of states to avoid attacking hospitals and to appropriately control their conduct of hostilities,” Liu said. “We deplore the lack of control over how hostilities are carried out. This free-for-all is a choice. There is a method in the madness. In both Yemen and Syria, four of the five permanent members of this council are implicated in some way in these attacks.”

While Russia has been bombing Syria, the United States, United Kingdom and France have been part of the Saudi-led coalition in Yemen that has made controversial drone strikes that have killed thousands of civilians. China also has been indirectly involved by supporting Russia with vetoes of U.N. resolutions relating to Syria. Liu called for independent investigations into attacks on civilians and medical personnel across the world and the appointment of a U.N. representative to document attacks on medical facilities.

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Photo: Karam Alamsri / MSF
Eleven-year-old Mohamed has shrapnel wounds to his head and body after air strikes on east Aleppo's Al Maadi neigh-borhood in early October 2016. He has been in hospital for four weeks, but cannot be discharged as his wounds need to be drained regularly. As a result of his injury, Mohamed has lost awareness of his surroundings and can no longer speak. He has neurological problems, including epileptic seizures, but the surgery he needs is not available in east Aleppo. "The main reason for neurological lesions are when sharp splinters of shrapnel enter the body or brain," says the hospital man- ager where Mohamed is being cared for. "Before the siege, we used to refer some neurological cases outside Aleppo. Now we don't have the proper equipment here for neuro-surgery, but referring people out of the city is not possible."

There have been repeated calls for war crime prosecutions in Syria from the United States, France and dozens of other countries. However, because Syria is not a member of the International Criminal Court, any referral to the court would have to be approved by the Security Council, a nearly impossible hurdle. Both Russia and China vetoed a draft resolution to approve such a referral in 2014 despite photographic evidence of the torture and killing of approximately 11,000 detainees by the Syrian government. In a largely symbolic move, the Russian government announced last November that it was withdrawing its signature from the statute founding the International Criminal Court, calling its investigations “one-sided and inefficient.” Several other countries, including the United States, China and Israel, also haven’t ratified the treaty establishing the court and its effectiveness has come under fire. The court has been accused of bias for focusing solely on African conflicts, and prosecutions have been hugely expensive, resulting in few or no indictments.

Experts worry that with little legal ramifications, the war on health care will worsen. The individual stories coming out of Syria have been horrific. Amputations occur without anesthetic. Patients have reportedly been shot by enemy forces while on the operating table. The few remaining doctors have been forced to provide care anywhere they can, from caves to chicken coops.

But the knock-on effect is just as chilling. Without personnel and basic medicines such as antibiotics, people die not only from bullets and bombs, but from routine, once-manageable diseases like diabetes. NGOs have accused government forces of systematically looting medical supplies from humanitarian conveys as part of a concerted effort to force rebel-held areas into submission through starvation and sickness.

The Red Cross and the Syrian Arab Red Crescent (SARC) condemned the bombing of a SARC humanitarian aid warehouse and convoy in rural Aleppo in September that killed 21 people, calling it a “flagrant violation of international humanitarian law” that could ultimately deprive millions of civilians from desperately needed aid for their survival.

The Red Cross set up refugee camps in November to help displaced civilians in Aleppo but is facing “tremendous difficulties” in reaching rebel-held areas of eastern Aleppo that are under intense bombardment, said Trevor Keck, deputy spokesman for the U.S. delegation of the Red Cross.

“It’s a pretty chaotic situation, and we can’t get clear guarantees from both sides of the conflict for safe passage into eastern Aleppo,” Keck told The Diplomat. “This is an unprecedented phenomenon. We certainly have seen attacks on health care centers around the world, but the situation that is most dark is in Syria. It sends a signal to the rest of the humanitarian community that protections afforded to them under the law won’t be respected.”

However, cooperation among some nongovernmental organizations working in Syria also has frayed. A position paper by the Syrian NGO Alliance representing 73 organizations working in Syria criticized SARC and U.N. agencies based in Damascus for making decisions “shaped by the political influence of the Syrian government.” The alliance stated it was suspending its participation in an information-sharing program in Syria and called for a revision of medical evacuation procedures and a transparent investigation of U.N. operations in Damascus.

“This deliberate manipulation by the Syrian government and the complacency of the U.N. have played hand-in-hand,” the paper stated. “The people of Syria have suffered ever more as a result.”

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Photo: UNICEF / UN018098 / Al-Issa
On April 26, 2016, health workers vaccinate a child in a medical center in Al-Radwanieh village in rural Aleppo. Because of Syrian President Bashar al-Assad's systemic bombardment of medical facilities in rebel-controlled areas, even basic health care services have been demolished, complicating childbirth deliveries, vaccinations and other once-routine services.

Humanitarian organizations are in the difficult position of criticizing Bashar al-Assad’s regime because they need the government’s cooperation to gain access to war zones. The Red Cross, which wasn’t mentioned in the Syrian NGO Alliance position paper, doesn’t get involved in “naming and shaming,” Keck said. The Red Cross, which hasn’t suffered any direct attacks in Aleppo, is a neutral organization that doesn’t seek international war crime investigations, and it conducts confidential discussions with various parties in a conflict to help ensure the safe delivery of humanitarian aid, he added.

While Doctors Without Borders has directly criticized countries involved in attacks on medical facilities, it also doesn’t actively seek war crime prosecutions, although it will provide information if those prosecutions are initiated by another party, Cone said. The organization also conducts confidential negotiations with warring parties to help deliver medical aid and protect medical personnel.

“We don’t have any illusions when it comes to the government of Syria,” Cone said. “With other governments and groups, there is more space for dialogue.”

The Syrian government has violated international humanitarian law by effectively criminalizing the delivery of health care to rebels early in the conflict, Cone said. “Once you’ve taken that step, it’s not that far a leap to bombing the hospitals themselves and killing the doctors you consider criminals just for providing medical care,” he said. “We do have a worry this is becoming normalized. In particular conflicts, it’s becoming normal to strike a hospital.”

The hospital attacks aren’t just killing medical personnel and rebels but also civilians. People are dying from lack of medical care, including women with complicated pregnancies and children who don’t receive vaccines for preventable diseases, Cone said. While investigations of attacks on hospitals are needed, international law is clear on the matter, he added.

“We don’t need a new Geneva Convention. The rules are sound and fit the purpose,” he said. “It’s just a matter of governments and rebel groups and others respecting them.”


About the Author

Brendan L. Smith (www.brendanlsmith.com) is a freelance writer in Washington, D.C.

Last Edited on January 4, 2017