THEMA

SYRIA

Translating Humanitarian Emergency into Medical Aid in Syria


Claire Glasscoe


BACKGROUND (page 2)





THE HUMAN COST IN REAL TERMS



The Syrian Centre for Policy Research (SCPR) produced a sobering report in February 2016 entitled 'Confronting Fragmentation'. This report makes clear the extent of the devastation in real terms. The population of Syria in 2011 was 23 million, but by 2016 it had fallen by 5 million when in normal circumstances it should have risen. Average life expectancy dropped by 15 years, from 70.5 years before the conflict in 2010 to 55.4 years in 2015. Many communities have been dismantled with over 50% of families displaced from their homes, unemployment is at 52.9% and 45% of children are out of school. Conservative summary estimates available of the key figures with their sources are as follows:

•     470,000 have died as a result of the conflict
      SPCR Report: Confronting fragmentation, February 2016
•     17,723 died under torture Amnesty International, August 2016
•     215,000 detained, 99% of which are in Assad's prisons Syrian Network for Human Rights May 2016
•     1.2 million have been injured WHO Annual Report – Syrian Arab Republic, Dec 2015
•     1,005,275 are living under siege; a further 1.4 million are on a watch list
      PAX & Syria Institute's Siege Watch Third Quarterly Report on Besieged Areas in Syria, May – July 2016
•     6.6 million are internally displaced
      EU Commission's Humanitarian Aid & Civil Protection Factsheet, September 2016
•     4.8 million are registered as refugees with UNHCR in Turkey, Jordan, Lebanon, Egypt, Iraq and North Africa
      Syria Regional Refugee Response Interagency Information Portal updated to 03/09/16
•     1,125,432 have sought asylum in Europe over 5 years of conflict
     UNHCR interagency information sharing portal July 2016

FATALITIES

The UN stopped counting the number of deaths in Syria in August 2014 and so there were and still are false reports of the figure being 230,000 until the more recent report by the Syrian Centre for Policy Research (SCPR). This report by SCPR puts the death toll at 470,000 by January 2016 and it has been cited as more realistic using their rigorous methodology although many put the real figure as high as one million.



Slide 11. Infographic circulated by SN4HR on Twitter from their report: Who is Killing Civilians in Syria.

The Syrian Network for Human Rights is an organisation that aims to document all fatalities in Syria. They have produced a breakdown of who they believe is responsible for killing civilians in Syria over the period of the conflict 15/03/11 – 01/03/16. While these figures don't capture the whole population of fatalities, based on this sample the authors lay an overwhelmingly large proportion of the blame for civilian deaths on the Assad regime: 183,827(94.7%) followed by the armed opposition: 2959 (1.5%), ISIS: 2196 (1.1%) and Russia: 1984 (1%) while the Kurdish forces, JAN and US-Led Coalition were each responsible for 0.2% after accounting for 1.1% unknown.

Data from the Violations Documentation Centre (VDC) locates casualties in precise areas in Syria, records the type of weapon used and distinguishes between civilian deaths and deaths of those who were a member of an armed group. They had recorded 132,858 deaths in total by 18/04/16 when I accessed the database, which again is only a fraction of the whole. Descriptive analysis of these data suggests that 93,891 were civilians representing (71%) of the total casualties recorded and 70,153 (74.7%) of these died as a result of shooting and bombing related incidents.



Slide 12. Civilian deaths over the period of the conflict in Syria with their causes for men, women, boys and girls extracted from the Violations Documentation Centre in Syria


A simple reading of the above chart, easily generated from the database for civilian deaths online without controlling for population characteristics, indicates the highest civilian casualties by gender and age are adult males with boys slightly outnumbering adult women. Adult male civilians are most at risk of being killed by ground and aerial shelling, shooting (snipers) and death under torture in prison. The figure for women and children combined is 25,888, which represents 27.6% of all civilian deaths. Women and children seem to be particularly vulnerable to aerial bombardments and ground level shelling. Professor Guha-Sapir and colleagues observed a similar result from this same database at a different time point and felt it may be due to the targeting of places where children and their mothers are present in large numbers, such as schools and hospitals. The proportion of women and children dying as a result of chemicals and toxic gas relative to male civilians was much higher than other causes of death at 431/980 representing 44%. This again may be a consequence of areas being targeted where women and children congregate but also their small bodies are likely to increase their susceptibility to the deadly effects of chemical and biological weapons. The above mentioned epidemiological paper published in the British Medical Journal on 29/09/15 by Debarati Guha-Sapir and colleagues Civilian deaths from weapons used in the Syrian conflict conducts a more sophisticated analysis than mine, and with their findings concludes that: 'using explosive weapons in populated areas in Syria has disproportionately lethal effects on women and children and should be urgently prohibited.'



Slide 13.'Kneel or starve' message signed by the soldiers of Assad with the Syrian flag, Medeya January 2016

DEATH UNDER TORTURE

Probably the most disturbing consequence of this conflict is the wide-ranging, gratuitous and systematic use of torture and sexual violence as a weapon against men and women. A despicable weapon that is hard to prevent, document, treat or hold the perpetrators accountable for. Under the anti-terrorism laws passed by the Syrian government on 02/07/12, any disloyalty towards the Bashar Al-Assad regime or support for the opposition in Syria was criminalised. Suspects were and still are arrested and imprisoned under torture for three years as a matter of course. A small sample of 55,000 photographs taken by one forensic photographer who defected, pseudonym 'Caesar' documenting 11,000 deaths in Assad regime detention facilities near Damascus have been on public display at the UN, the British Houses of Parliament, the Royal Hibernian Academy in Dublin, the Holocaust Museum in New York and most recently the Nobel Peace Center in Oslo to convey to the world the true horror of life and death in Syria. Human Rights Watch conducted in-depth investigations into 27 of the individual deaths identified by the photographs documented by 'Caesar' in their document: If the Dead Could Speak. Amnesty International has also reported recently on atrocities – abductions, torture and summary killings committed by armed opposition groups operating in Idleb and Aleppo. This report blames al-Shamia Front, the Nour al-Dine Zinki Movement and Division 16 who all joined the Aleppo Conquest Coalition in 2015 and Jabhat al-Nusra and the Ahrar al-Sham, Islamic Movement in Idleb that also joined the armed conquest coalition that same year. Yet these violations are far outweighed by those perpetrated by the Assad regime. According to a report by UK-based Syrian Network for Human Rights (SNHR), the number of Syrians tortured to death since the outbreak of the uprising in March 2011 reached 11,429 by 26/06/15. A figure revised by Amnesty International, which put the total figure at 17,723 in a report dated 17 August 2016 by their Human Rights Data Analysis Group. The relative contribution of these atorcious human rights violations set out in the SNHR report was as follows: 11,358 (99%) Government Forces; 31 deaths under torture attributable to the Armed Opposition; 29 to ISIS; 5 to the then named Jabhat al Nusra; and, 5 to Kurdish Self-managed forces. Consistent with these data supplied by SNHR, the overwhelming majority of the victims Amnesty International documented had suffered at the hands of forces loyal to President Bashar al-Assad. Moreover, what is important here is whether there are mechanisms in place to deal with the perpetrators of human rights violations by the offending parties? None, it seems in the case of the Assad regime, on the contrary these bestial violations by any civilised standards are endorsed as Assad regime policy and applauded.

The 'Assad Files' is an investigation described by Ben Taub in the New Yorker on 18/04/16 that brings these naming and shaming exercises by various organisations together as a coherent preparatory move towards prosecution of the main person responsible – Bashar al Assad. These documented acts of violence amount to war crimes and crimes against humanity so whether the victims were civilian or not is an irrelevant question. In addition to what is known though is also what is not known about a further group of detainees in secret, unofficial detention centres located underground, such as Der Shmiel. These detention centres are where most of the 'disappeared' of Syria end up and don't survive to be able tell anyone what happened. For those whose loved ones are missing the SNHR provide a search engine to locate them or register their absence. There are 106,835 entries. The most recent SNHR report on enforced disappearances inside Syria.

The problem with the numbers of conflict related deaths drawn from surveys and incomplete databases is that despite their best efforts, no organisation has been able to record the whole population and therefore there is risk of under-reporting and bias unless the sampling is conducted in a methodologically sound way. As the UN stopped counting fatalities in Syria in August 2014 the widely reported total figure of 230,000 dead is a gross underestimate. Yet this is double the figure supplied at that time by VDC, which contributed to the UN figures and half the figure of 470,000 presented by SPCR, which is half what many believe to be the true figure. I don't think this means we should discount the findings of the smaller samples, in fact qualitative documentation of stories as this website seeks to do, are just as relevant and in many ways more illuminating where the stories are describing shared experiences that can be verified and investigated or accessed to gain a further understanding on the situation in Syria. There are excellent websites that achieve this: Syria Deeply describes the story of this global crisis. I Am Syria aims to educate the world about the conflict and what it means to be a Syrian refugee and Enab Baladi is an underground news station reporting everyday events from Daraya inside Syria. Their work is celebrated here by Sergio Perez as he revisits how the August 2012 massacre in Daraya was reported 4 years on.

Whichever way these findings are read though there is no doubt in my mind that this man-made catastrophe is a travesty of justice of gargantuan proportions, which rivals that of Rwanda and exceeds that of the former Yugoslavia in its death toll and sheer brutality. The state sponsored narratives of: 'Assad or we burn the country,' 'surrender to the government or starve' and 'anyone who opposes the government is a terrorist,' insight gross violations of human rights that are steering the country domestically towards demographic change and ethnic cleansing that needs to be referred to the International Criminal Court.



Slide 14.From a series of photographs by Khaled Barakeh entitled 'Fabric of life' – depicts the shields civilians create to protect themselves from Syrian regime sniper fire

CONFLICT RELATED INJURIES

Handicap International (HI) is an organisation concerned with disability in situations of poverty and exclusion, conflict and disaster that has been working inside Syria for four years and during that time they interviewed a significant sample of 1847 people who were internally displaced with a disability. Of those, 913(45.5%) were injured as a result of the conflict. In 60% of cases, these injuries were declared to be the result of bombing or shelling and 31% were due to gunshot wounds. [Causes and types of injuries. Their interview data then reveals the types of injuries reported as a consequence of explosive weapons inside Syria. In their sample they found a predominance of fractures (60%), followed by a wound (28%) and a massive proportion (25%) had an amputation. While these researchers acknowledge the limitations of their study these findings are corroborated elsewhere. The Syrian American Medical Society (SAMS) is a Non Government Organisation (NGO) providing medical relief to most areas in Syria. In their testimony to the US House Foreign Affairs Committee on the Humanitarian Crisis in Syria, which was posted on a blogspot by Zaher Sahloul on 02/07/14, SAMS predicted that 'at least 600,000 Syrians had sustained a lifelong disability, including amputation, spinal cord paralysis, [severe] burns, brain damage and loss of eyesight, due to shrapnel, sniper bullets and indiscriminate bombing by all kinds of prohibited weapons'.

Amputations

This highlights the scale of the problem for medical services, particularly the provision of prosthetic and orthotic treatment plans if as HI found 25% of those injured had an amputation. The National Syrian Project for Prosthetic Limbs is one of several centres on the border-zone in Turkey providing this much needed service to restore mobility to those who have lost limbs.

Damaged Eyesight

Another field study in Syria estimated that 25% of head injuries involved trauma to the eye. Many of these injures would be straightforward to deal with in normal circumstances but they are virtually impossible to treat inside opposition held Syria. The Syrian British Medical Society responded to this call and in April 2014 established an ophthalmic clinic on the border-zone in Turkey. Over the first year 11,000 Syrian patients were seen for a general ocular assessment and treatment of which 15% resulted from an eye trauma injury.

SEXUAL VIOLENCE

Concerns over sexual violence were recognised early on within the hostile environment that Syria has now become. Lauren Wolfe, Director for the Women's Media Centre (WMC) gave evidence to the United Nations on sexualised violence inside Syria on 18/07/12. This project group had collected 81 stories with enough detail to present as 117 separate datasets of sexual humiliation and death. Of these 117 reports, 80% involved female victims, with ages ranging from 7 to 46, while 24 incidents involved men and boys aged between 11 and 56 years. Rape was alleged in 89% of the women's witness statements and 33% of the men's statements. Rape and/or sexual assault led to death in 20% of female victims' reports. '“Death” here means that women were found dead with signs of sexual assault or they were raped and then killed in front of witnesses.' A further 5% of cases resulted in pregnancy. Witnesses in 75% of the cases involving women were able to identify the perpetrators as members of Government forces (50%) and those termed 'shabiha' (17%) ('shabiha' at this time was a term used for pro-regime militias financed by businessmen, exclusively from Alawi or Shia sects) or a combination of the two (8%). For the men Government forces were blamed for perpetrating all but one of the sexual assaults.

In December 2012, the International Federation for Human Rights (FIDH), in collaboration with the Arab Women Organisation (AWO), sent an international fact-finding mission to meet with Syrian women who had fled the crisis and sought refuge in Jordan. They visited and had meetings with women in three refugee camps, Al Za'atari, King Abdullah Park and Cyber City and additionally held meetings with 80 refugees living outside “official” camps in Amman, Rusaifa, Dhleil and Sama Sarhan (Zarqa Governorate). One of the consequences of large numbers of men being killed in this conflict is for women to become, by default head of households. This shift in role makes women vulnerable to abuse and exploitation and for the majority the fear of rape had motivated their decisions to leave Syria. As in the WMC study, women reported that Government forces and 'shabiha' were the perpetrators in most allegations of rape and other forms of sexual violence. The attacks took place during house searches, when they were stopped at checkpoints and while they had been detained in prison. Many women also talked of the risk of kidnap, by all parties to the conflict, in order to obtain information or as bargaining tools for prisoner exchanges. Those who survived rape were sometimes forced into marriage, in order to “save family honour” and girls may be married at a young age to afford them some protection against unwanted attention or to raise money through a dowry to feed the rest of the family. A culture of silence prevails because those who have been abused in this way risk stigmatisation and rejection from their community, which means that those in need of physical and therapeutic help following sexual violence do not access services even after they have sought refuge outside the country.

MENTAL HEALTH

The other grave concern for the Syrian civil society is for its mental health. Doctors who are working with Syrians on the border-zone readily admit they are all in need of psychiatric help because of the unrelenting death, destruction and carnage they have experienced. But scarcity of resources precludes any help for these helpers.

Omar Karasapan, Regional Coordinator for the World Bank writing for the Brookings Institute warns of a mental health crisis in Syria after extrapolating from studies of refugee populations. Those with pre-existing or emerging mental illness or neurodevelopmental disorders are not being treated and the conflict is exacerbating their conditions. Furthermore, Omar Karasapan cautions that stigmatisation around the issue of emotional and psychological disorders within Arab culture, often prevents those in need taking up the scarce resources available. He suggests one approach to ameliorating this situation would be to assimilate services for mental health into the general healthcare provision.

Humam Saltaji and Saleem Al-Nuaim writing in the Lancet on 20/02/16 point to guidelines written by the Interagency and Standing Committee on mental health and psychosocial support in emergency settings. Those guidelines aim to establish a minimum set of multi-sectoral responses to protect and improve people's mental health and psychosocial wellbeing in any humanitarian emergency. The focus is on delivering minimum yet essential responses that should be implemented as soon as possible in an emergency.



HEALTHCARE TARGETED



With so many extensive and complex injuries, good healthcare is essential. Perversely though, the systematic targeting of healthcare has been a cornerstone of the regime's strategy to undermine the revolution. Healthcare for those opposing the regime was criminalised with anti-terrorism laws passed by the Government in July 2012. This resulted in half of the 30,000 qualified doctors leaving Syria. Those that remained are either located in regime controlled parts of the country, where these new laws compromise their medical ethics, or have moved to the 'Free' areas, where on-going training is non-existent and the risk for arrest or a violent death is high. Abbara, BMJ, June 2015; 350:h3479 In the UN Human Rights Council (OUNHC), Independent Inquiry Report on Syrian Arab Republic dated Feb 2015. Item No. 8, on page 12, addresses 'Medical Personnel and Humanitarian Aid Workers' and paragraphs 80 and 81 refer to the 'failure of the state to protect civilians and link[s] this to the collapse of the Syrian public health system,' which has been accelerated by the loss of medical personnel: 'Ambulance drivers, nurses, doctors and medical volunteers have been attacked, arrested, unlawfully detained and disappeared' and 'Hospitals and medical facilities have been systematically targeted, leading to the death and wounding of medical personnel.' Paragraph 83 then references humanitarian aid workers: 'Violence targeting humanitarian workers and facilities continues to obstruct the efforts of humanitarian agencies to deliver aid to those Syrians most in need.'

The Physicians for Human Rights (PRH) organisation have produced an interactive map of attacks on medical facilities in Syria and the number of healthcare personnel killed.

For Syria as a whole, PHR records up until June 2016 show an average of one healthcare worker was killed every other day:

•     757 have been killed since the beginning of the conflict
•     382 healthcare facilities have been attacked

The PHR report about Syria's Medical Community Under Assault, dated February 2015 makes the point that these are crimes against the principle of medical neutrality, which should ensure safe access to medical facilities, protect healthcare workers and their patients. Targeting these facilities and staff has compounded civilian suffering and led to the demise of the healthcare service.

Between the start of the conflict until February 2016 they recorded 100 attacks on healthcare facilities in Aleppo alone with 104 personnel killed. The Syrian Government and/or Russian Forces are believed to have perpetrated all of these attacks apart from three.

AL QUDS HOSPITAL, ALEPPO

One recent example of this form of targeting is in Aleppo where the city is divided in half (Slide 9) with the east (green) being opposition-held and the west (red) being regime controlled – Kurdish Rojova (Syrian Democratic Forces) control the yellow area.

The Mail online graphically illustrates the devastation in opposition held and regime held areas and the Syrian Observatory for Human Rights recorded the casualties on both sides. Over nine days from dawn 22nd April until the afternoon of the 30th April, 253 people were killed in Aleppo: 145 were killed in airstrikes carried out by warplanes (Assad regime or Russian) and a further eight by Assad regime shelling. In regime-controlled areas of western Aleppo, 100 people were reportedly killed by shells, rockets and explosive cylinders fired by the opposition.

The MSF backed hospital AlQuds in the Sukkary neighbourhood of Aleppo was hit by at least one airstrike and took a direct hit at 10.00pm on 27th April. The death toll rose over the next few days to 55. This was the fifth time it had been targeted said Hasan al Haleeb, Medical Director talking to Bilal Abdul Kareem at the bombed site for 'Face the Truth' posted on Youtube on 04/05/16. The staff residential accommodation next door was also damaged and they were still pulling out the bodies from the wreckage three days later; 55 were estimated dead at that point. Hasan al Haleeb was able to identify the weapon used as a vacuum bomb by the pattern of damage it created, but he was not sure whether it was dropped from an Assad regime or a Russian plane.



Slide 15. Image of destroyed MSF backed hospital tweeted by Raed Fares at Kafranbel Media Centre
an hour after the strike on 27th April 2016 Al Quds Hospital hit by a government
airstrike in which at least 27 staff and patients were killed
    
Slide 16. Casualties form the airstrike on 27th April      Slide 17. Dr Muhammad Waseem Maaz, Aleppo's most qualified paediatrician was killed in the attack on Al Quds Hospital

Lisa Barrington and Stephanie Nebehay reporting for Reuters wrote: 'after six days of air strikes and rebel shelling, the MSF backed AlQuds Hospital was destroyed when it suffered a direct hit from an air bomb. It was the main referral centre for paediatric care and three medical staff were killed, amongst them Dr Muhammad Waseem Maaz, the city's most qualified paediatrician.'

To add insult to injury Hadi al Abdallah, an independent Syrian journalist had his footage of the devastation in opposition held Aleppo misappropriated by Russia Today news channel, which edited his commentary to tell a different story – that the attack on AlQuds hospital was the work of the AlQaeda affiliate Jabhat al Nusra. Hadi al Abdallah tweeted an angry complaint calling for an advocate to press charges against the offending news agency on his behalf



Slide 18. Tweeted message from Hadi al Abdullah in response to Russia Today falsifying the content of his report on the bombing of AlQuds Hospital on 27/04/16



AlQuds Hospital was no accident as it was not the only medical facility to be hit that week; on 29/04/16 four more healthcare facilities were hit in eastern Aleppo. The correspondent from ElDorar AlSharmia News Network in Idleb reported these strikes. On that day, airstrikes hit Al Marjeh Medical Centre in the Marjeh district of Aleppo; Bustan Alqasr Medical Centre; Shawki Hilal Dialysis Centre in Jeb Al Qubbah neighbourhood and Ibn Rashid Cardiac Hospital all in opposition-controlled areas. The International Committee of the Red Cross appealed for all sides to stop the indiscriminate violence and destruction . But the opposition then declared a renewed offensive as Government and Russian forces were blatantly violating the ceasefire. And three days later an explosion severely damaged AlDabeet Maternity Hospital in the regime-controlled part of Aleppo, killing 14 civilians. This was blamed by Syrian and Russian State news agencies on opposition forces as part of their declared offensive with rockets. The FSA issued a statement denying the claim of their involvement in targeting a hospital as this would contradict their stated military ethics and they made a counter claim that the regime itself was responsible. The Syrian Human Rights Committee assessed the damage was more likely due to a car bomb and not a rocket which is the signature of extremist groups and given its location the strike would have been hard to accomplish with a surface-to-surface rocket. It remains unclear what group was responsible but it may well have been an extremist group seeking to destabilize the peace negotiations with western backed opposition fighters.

Back in 2014 the World Health Organisation (WHO) reported over half of Syria's public hospitals either non-functional or partially so because of deliberate targeting. More recently, Médecins sans Frontieres (MSF) informed Sputnik on 02/05/16 that airstrikes were not only hitting hospitals but have struck warehouses in which medical donations and equipment were stored before being delivered to healthcare facilities. In the case of Aleppo this included the Pre-Hospital System managed by the Aleppo Directorate of Health, to which MSF is one of the donors. Civilians working in the warehouses have been killed in these attacks and essential items such as specialist medical donations, and equipment such as ambulances have been destroyed.

But the Syrian Government seems to support a view that any medical facility in an opposition-held area supported by MSF was fair game and they only have themselves to blame if they were targeted. This statement by Bashar al-Jaafari reported by Richard Spencer in the Daily Telegraph makes that very clear: 'Bashar al-Jaafari, the Syria ambassador to the UN in New York and chief negotiator for the regime at peace talks, was also asked about the attack [on the MSF supported hospital in Maraat al-Numan on 15/02/16], to which his response was: "The so-called hospital was installed without any prior consultation with the Syrian government by the so-called French network called MSF, which is a branch of the French intelligence operating in Syria".



Slide 19. Types of weapons used and their effects in the Russian backed Assad regime aerial bombing and shelling offensive on Aleppo during August 2016.
Published by the Syrian Institute for Justice

The statistics for the casualties from the aerial bombing of Aleppo during the whole of August 2016 is contained in an info-graphic totalling 500, which contrasts with the same dataset for March 2016 when the total number of victims was 49 highlighting the intensification of the Assad regime/Russian assault.

TRAINING

Doctors working in Syria are well aware of the risks involved and many have made sure their families are safely located over the border in Turkey. Dr Muhammad Waseem Maaz's family was in Turkey. He hadn't seen them for four months and was due to see them over the weekend when he was killed on 27/04/16 in AlQuds Hospital. Working under these conditions is extremely challenging and training, in service or otherwise is nigh on impossible. Dr Maaz was highly qualified but healthcare personnel that left regime-controlled areas before finishing their training are most likely practicing in 'Free' areas without a qualification. Learning on the job is the order of the day so there is a great need for formal teaching to progress their status to become licensed practitioners both for now and for the future of Syria. The Nott Foundation spearheaded by Dr David Nott, OBE is one project aiming to train surgeons in the complex surgical procedures required in a warzone because of the complicated injuries incurred from explosive weapons.

These interventions though are merely a drop in the ocean of need as there is a critical shortage of medical facilities, medical supplies and qualified physicians and paramedics. They are now running out of coffins because soon there will be no life left in Aleppo, warns Osama Abo El Ezz, a general surgeon with SAMS writing for the New York Times.

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