Syrian hospitals under siege: When a red cross becomes a target

Through February 2016, Physicians for Human Rights documented 358 attacks on medical facilities.

heislerProviding medical care in a war zone is never an easy task, but doctors in Syria’s opposition-held areas face particularly extreme circumstances as their hospitals become targets for bombing campaigns. Michele Heisler, a researcher and professor at the University of Michigan, spoke with the doctors working under these conditions on behalf of Physicians for Human Rights. She outlines what she learned about the state of healthcare in the Syrian city of Aleppo, what motivates the doctors providing it, and implications for the concept of medical neutrality.


ResearchGate: In what capacity did you conduct the assessment you published in the New England Journal of Medicine?

Michele Heisler: My coauthor Elise Baker and I went to southern Turkey last year, where there was a meeting of physicians from Aleppo. Aleppo is the largest city in northern Syria and has been divided by the conflict for the last couple of years. The opposition have controlled eastern Aleppo, and the government continues to control western Aleppo. Because it’s opposition controlled, eastern Aleppo has experienced frequent attacks. The main aims of our study were to figure out what the situation with health infrastructure there was and how health professionals are managing.

We conducted the project on behalf of Physicians for Human Rights. The organization documents attacks on health professionals and medical facilities, violations of medical neutrality, throughout the world. Because there’s been such a high number of incidents in Syria, the approach to documenting violations there since the beginning of the civil war has been particularly systematic.

RG: What kind of medical facilities were operating in Syria at the time of your visit?

Heisler: There was a range, from very sparsely equipped and staffed medical points that work primarily to stabilize and triage patients and send them to better-equipped facilities, to hospitals with surgical capacities. In Syria it really varies, because in the government-controlled areas, there haven’t been aerial attacks on hospitals. But certainly in places like eastern Aleppo all of the facilities are pretty under-equipped.

RG: Who is staffing them?

Heisler: There are doctors, nurses, medical students, medical volunteers, all of whom are of course overstressed. They all are working very long hours and beyond their areas of expertise. It was striking to us in the interviews just how remarkably innovative the staff have been, making do with limited resources. For example, there are no kidney doctors in all of eastern Aleppo now, but they did have about three functioning dialysis units at the time of our interview. They’ve been innovating ways to do dialysis that conserve limited resources. You also have pediatricians who’ve had to learn how to do surgery and general surgeons trying to do vascular surgery. They’ve been remarkable at triaging to save lives, but at very high cost in terms of people’s quality of life. One general surgeon explained that he can save a life by cutting off a leg, but with the sadness of knowing the leg could have been saved by a surgeon with different expertise. And so lives are being saved in many cases, but there’s no physical therapy, and almost no mental health resources for the very high rates of PTSD.

RG: What types of attacks are medical facilities experiencing?

Heisler: In opposition-controlled areas, the medical facilities are being directly bombed by Syrian government forces and were heavily bombed by Russian forces as well. Some attacks are with missiles, bombs, and rockets delivered by war planes. The most gruesome attacks we outline in the report are with barrel bombs, which are packed with nails and all sorts of things that will shatter. They just wreak horrendous havoc, affecting up to a city block. They tend to explode throughout people’s bodies, so the types of injuries are really horrific.

Physicians for Human Rights has also documented some attacks on medical facilities by opposition groups and by ISIS. These are usually with shelling and car bombs, as these groups don’t have the military capacity for aerial bombardments. But these attacks are much fewer. Through February 2016, PHR documented 358 attacks on medical facilities, and 91 percent of these were by Syrian government and Russian forces.

RG: Last month, Vladimir Putin announced the withdrawal of Russian forces from Syria. How has the situation for healthcare workers developed since then? 

Heisler: Russian forces have not actually withdrawn from Syria. While flying some warplanes back to Russia, they shipped in more advanced helicopters, which are now being used to launch attacks. The cessation of hostilities that came into effect in late February has caused a significant reduction in violence, and it has certainly saved hundreds of lives. But attacks have not stopped. At the end of March, Physicians for Human Rights documented an attack on a hospital in Latakia, in northern Syria along the border with Turkey. Syrian government forces shelled the hospital and a nearby physiotherapy center, forcing them both to close. And just April 13, an airstrike killed a doctor as he was leaving his hospital in Hama. He was the health director for the region. His death is an incredible loss to Syria’s medical community. So these attacks are continuing despite the ceasefire and supposed Russian withdrawal.

It became clear the red cross was more a target than a shield”

RG: Is it typical for medical facilities to be targeted in conflicts? How does the current case in Syria compare to historical precedent?

Heisler: What we’re finding is that this is increasingly becoming the new norm. That’s the reason this is such an important issue, and we’re thrilled the New England Journal published our perspectives piece on it. We’re seeing attacks increasing around the world. Since the Geneva Convention in the late 1800s there was a period in which medical neutrality was largely observed, though there were other atrocities certainly. But today we’re seeing increasing violations. Other places where medical facilities are clearly being targeted are Yemen, Afghanistan, and South Sudan. Still, in terms of the scope and scale of attacks, there really hasn’t been anything like Syria. In Syria, you get the sense that attacking healthcare facilities, killing doctors and other healthcare professionals is really part of a systematic strategy. Physicians for Human Rights has documented the deaths of 726 medical personnel through February 2016. This also includes attacks on ambulances and first response teams, part of a strategic obstruction of medical aid to opposition controlled areas.

RG: The Geneva Convention states that “zones established to shelter the wounded, sick and civilians must not be attacked.” Is that a realistic rule in wars where it’s hard to tell who is civilian and who is not?

Heisler: When Physicians for Human Rights started looking into this issue, we expected to mostly see collateral damage. But as we started sifting through all the evidence, it became clear that it usually wasn’t. Most of the major hospitals stand alone—they’re not near any buildings that could be a military target—and were clearly marked until it became clear the red cross was more a target than a shield. Even if they hadn’t been marked, they’re big and they’ve been there for years. Everyone knows where and what those buildings are, just like a major hospital in any large city around the world. We even looked at satellite imagery to rule out the possibility that there were mobile military targets like armored vehicles in the area. There are some cases where the government announced they were targeting a specific doctor, who was subsequently killed in a strike on a hospital. The attacks on the medical facilities are clearly not collateral damage. They’re deliberate attacks on civilian areas.

Not only are civilians and civilian objects like hospitals not supposed to be targeted, but even when targeting legitimate military objects, a military or armed group must assess the risk of damage to civilians and only pursue the attack if the military advantage is proportional to the risk of civilian casualties. If they do go ahead, they must give warnings to civilians. There’s not a single report of any precautionary measures being taken. So yes, the simple answer is that it is a realistic rule, and it’s not being followed.

RG: Is there anything the doctors on the ground brought up in interviews that really stuck with you?

Heisler: There is incredible inspiration in the motivations of the physicians. One of the physicians I spoke with had actually gone to Germany with his family and was going to have the opportunity to continue his advanced training in pediatric surgery, but he came back. He said he thought, “I am Syrian. I am from Aleppo. How can I live with myself as a doctor if I don’t go back and help the people in my city?” We’re saying, “Gosh, how can you do this?” and they’re saying, “How could I not do this? I’m a doctor.” Many of the people we interviewed told us about a colleague—one of the few female physicians still there—who hasn’t left Aleppo once since the beginning of the conflict. She says women will die in childbirth if she leaves. A lot of the physicians actually had their families in southern Turkey, and they would go back and forth. They’d spend 15 days, 24/7 in the hospital and then they’d take a break and go to southern Turkey. Now many of the routes to southern Turkey are cut off, and the city is close to being besieged. The physicians also told us how they tried to keep their spirits up. One person said that when the barrel bombs started falling, he and his colleagues would sing. They refused to be kept away.

“Using medical and scientific evidence to advance the cause
of human rights”

RG: Is there a trend of medical care moving away from hospitals to less centralized locations?

Heisler: Definitely. They’re hiding. They can’t move the hospitals. They considered that, but it’s very easy to find out where they’ve been moved to. When possible, they’re moving operations to the basement.  Some hospitals leave the top floors empty, so they can absorb the bombs. They’re trying to do things like put sandbags around the facility and keep the lights off. And as you say, they’re working increasingly in mobile units, teams of doctors, nurses, and technicians providing medical care to civilians outside of medical facilities. That’s very difficult. They don’t have the kinds of equipment and facilities for many of the surgeries people need, but they’re doing what they can.

RG: What can the international community do to assist medical professionals in conflict areas?

Heisler: The UN Security Council has passed resolutions specific to Syria calling for an end to attacks on medical facilities and civilian areas. The key thing is to enforce these resolutions as long as the attacks continue and increase. Unfortunately attacking medical facilities is a very insidious and effective way to terrorize populations. The concern is that if this becomes the new norm, it could become a weapon of war throughout the world. When Syria started to use chemical warfare against civilians, the international community pushed back and was largely successful. We need to take a similar approach to these violations and make it clear that they are absolutely unacceptable.

RG: Could you tell us a little more about Physicians for Human Rights? How did you, a diabetes expert in Michigan, become involved in a human rights investigation in Syria?

Heisler: Physicians for Human Rights sponsored a class at Harvard on health and human rights when I was a medical student there. A lot of us took it and were inspired. That’s when I first wanted to become involved, and I was able to contribute even more when I developed research skills. Physicians bring a lot of skills to this kind of work. Not just the ability to do physical examinations and psychological evaluations, but for those of us who are researchers, also survey methods and statistical skills. So even without going into the field—when I was doing my residency, working as a junior faculty member, having kids—I was able to use my experience in academic medicine and health services to help do analyses and rigorous research for Physicians for Human Rights. That’s their mission in the human rights world. Whether it’s forensic documentation, pathologists who are experts, epidemiological techniques, they’re using medical and scientific evidence to advance the cause of human rights. So for me, my work with diabetes and work for Physicians for Human Rights isn’t that different. It’s all using research for advancements in human rights and social justice.

Featured image from Physicians for Human Rights' interactive map of attacks on Syrian medical facilities.