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'.
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.
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.
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.
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.
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.
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
Casualties form the airstrike on 27th April
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