IDPs in Jabal Al-Akrad, in Syria's Latakia region. Credit: Shelly Kittleson/IPS

By Shelly Kittleson
REYHANLI (TURKEY), May 19 2014 (IPS)

As once-eliminated diseases resurface and barrel bombs and alleged chlorine attacks target civilians, doctors in rebel-held areas and across the border struggle with issues of how best to serve their profession.

Up to 70 percent of Syria’s health workers had fled the country as June last year, according to the World Health Organization, and many of the country’s medical facilities have been destroyed or heavily damaged by regime air strikes.

‘’Even blood bags are controlled by the ministry of defense...You go to jail if they find you with one" -- Dr. Omar
Though regime and opposition fighters are often said to share the blame for obstructing access to medical care for civilians, Dr. Omar, who works with the Syrian Expatriate Medical Association (SEMA), said that his organisation has not experienced problems with any rebel groups while working in Syria. However, he stressed that his work ended when the patient – whether rebel fighter, regime soldier or civilian – had been treated.

“My work stops there. What they do with them afterwards is not my business,” he said, stressing the need for neutrality in order to continue operating in areas even when they change hands from one group to another.

Doctors Without Borders (MSF) has long been known for the same code of ethics, but nevertheless had five of its expatriate staff taken hostage in early January, most likely by the fundamentalist group Islamic State of Iraq and Al-Sham (ISIS). More moderate factions have pushed the extremist group out of much of rebel-held territory in the north in recent months but the medical workers’ whereabouts remain unknown.

MSF decided to pull all foreign staff from Syria after the incident but continues to operate several makeshift clinics and mobile facilities in the country using Syrian personnel. It also supports local hospitals.

The international NGO – which, Dr. Omar notes, was ‘’the first group to send us money and support in 2011’’ – has not been able to register with the Turkish government and is thus unable to establish official offices across the border.

He said that he had recently been in Kasab, part of a coastal area seized in late March by rebel fighters, to set up medical facilities for ‘’damage control and sending them elsewhere. That’s all we can do right now’’.

Save the Children recently reported cases of doctors forced to give children unnecessary amputations and patients choosing to be knocked out with metal bars rather than undergo surgery without anaesthesia, which is in short supply. There have been outbreaks of vaccine-preventable measles and polio that have begun to spread across the country’s borders.

Dr. Omar initially left regime territory in early 2012 to avoid arrest, after working as one of the first to coordinate clandestine treatment to those injured in protests across the country. The work involved considerable risk, because ‘’even blood bags are controlled by the ministry of defence, not by the health ministry.”

‘’You go to jail if they find you with one,’’ he said.

He was later one of four doctors working inside the country who met secretly with Syrian expatriate medical staff in the Turkish border town of Reyhanli in November 2011 to start working alongside the Union of Syrian Medical Relief Organizations (UOSSM).

Of the other three doctors, “one has been killed under torture, Mohammad Osama Baroudi, one has been in prison since 2012, and one is working at a field hospital inside.’’

At least 440 medical personnel have been killed in the ongoing conflict, reports Physicians for Human Rights, while many hundreds of others continue to be held in regime detention facilities.

The border town where Dr. Omar works when he is not inside Syria has changed dramatically since this IPS correspondent’s first visit in 2012. A few makeshift care facilities and injured fighters propped up on porches under ‘internet café’ signs or treated in disused hotels and homes have been replaced by a more organised system.

Several medical facilities cater to the masses of injured, amputees and patients with spinal cord injuries who have made it to this side of the border, and ragged-looking Syrian children begging in the streets are a common sight. A clinic specifically for prosthetics, the National Syrian Project for Prosthetic Limbs (NSSPL), has been set up on its outskirts, and short courses are held for would-be physical therapists, many of whom are medical students forced by the conflict to abandon their studies.

A 29-year-old physiotherapist working here told IPS that he had been arrested in early 2011 on terrorism charges and briefly joined a rebel group after being tortured in jail. He found, however, that he was unable to make himself kill anyone. He claims to be one of only a few fully trained and medically certified Syrian physiotherapists now in the town, as he graduated from the faculty set up in 2006 in Homs that closed only a few years later when war broke out.

He and his younger brother were taken from his house in the middle of the night, and he spent ‘’34 days, 6 hours and 28 minutes’’ in detention. His family eventually found a trusted contact to whom they paid 30,000 dollars to have him released. His brother, who worked with the Red Crescent, is still in prison. His family has meanwhile paid several thousand dollars to get him moved to detention facilities where they can occasionally visit him and refuse to leave the area unless his brother comes with them.

The physiotherapist feels he can be more useful here than inside, but admits: ‘’I am afraid of myself. If I go back inside I know I won’t come out again. My old friends would like me to work with them again. But I am still wanted by the regime and would put my family in even more danger than they already are.’’

Syrian refugee children learn to survive at a camp in north Lebanon. Credit: Zak Brophy/IPS.

By Katelyn Fossett
WASHINGTON, May 14 2013 (IPS)

Humanitarian assistance groups in Washington are warning that the health care system has become a deliberate target in the increasingly brutal civil war in Syria, presenting major challenges to addressing the humanitarian and refugee crises spurred by the conflict.

In a meeting with U.S. President Barack Obama on Monday, UK Prime Minister David Cameron stressed the centrality of the unfolding health crisis, emphasising the need in Syria to “care for trauma injuries, help torture victims to recover, [and get] Syrian families clean drinking water”.

Health aid is meeting significant obstacles, though, as the public health system in Syria reportedly has been largely dismantled after being targeted by Bashar al-Assad’s regime, which has wiped out a third of the hospitals in the country.

“The systematisation of the attacks [in Syria]…certainly served its purpose,” Stephen Cornish, executive director at Médecins Sans Frontières (MSF) in Canada, said recently at a panel discussion in Washington. “It created a flight of many medical personnel and destroyed large numbers of hospitals and interrupted public healthcare in a significant way.”

According to the Violations Documentation Centre, a Syrian human rights organisation based in Damascus, 469 health workers are currently imprisoned in Syria. Tom Bollyky, a senior fellow at the Council on Foreign Relations, a Washington think tank, estimates that around 15,000 doctors have been driven out of the country.

Bollyky noted that these attacks are one conflict’s manifestation of a disturbing global trend in which medical facilities and personnel become more frequent combat targets in conflict zones. In a March report, the Independent International Commission of Inquiry on the Syrian Arab Republic accused the Assad regime and opposition groups of strategically targeting medical facilities and personnel."Attacking medical personnel is a way of depriving a population of the humanitarian support they need."
-- Tom Bollyky

“Attacking medical personnel is a way of terrorising a population and depriving them of the humanitarian support they need,” Bollyky told IPS.

He pointed to similar instances in the Middle East and Asia, particularly coordinated attacks by the Taliban on polio immunisation volunteers in Afghanistan and Pakistan. On Monday, the Taliban announced it was halting its years-long effort to sabotage the campaign to eradicate polio among children in these two countries.

Such attacks are specifically outlawed in the Geneva Conventions, which entitle hospitals and medical staff to protection from hostile fire.

“Medical personnel are absolutely protected under international law,” Bollyky noted. “There is no circumstance where it is okay to attack medical personnel or facilities, and it is certainly happening on both sides.”

Silent casualties

The targeting of the Syrian health care system has not only left those wounded by combat without urgently needed care but has also exacerbated a public health crisis brought on by the poor living conditions of refugee camps outside of Syria.

Refugees from the conflict currently number more than one million, and the United Nations is warning that figure could swell to 1.5 million by the end of this year. That number is dwarfed by the more than 4.2 million Syrians who are displaced within Syria.

In addition to the systematic targeting, Syrian medical facilities are reportedly being “cannibalised” to serve military ends.

Zahir Sahloul, a doctor with the Syrian American Medical Society, told an audience on Friday about the looting of the two main hospitals in Aleppo – an eye hospital and a children’s hospital – that now serve as bases of operations for military battalions.

“Besides the destruction of the public health system, there is no sewer system,” Sahloul said “[There is a] lack of hygiene because of lack of electricity and sometimes water…and lack of diesel fuel. And because of that, you have a resurgence of some of the epidemics that weren’t there before.”

Chronic illnesses that were relatively easily treatable before the outbreak of the conflict – diabetes, or high blood pressure, for example – are now deadlier than ever, leading to what MSF’s Cornish called “silent casualties”.

These patients can’t be referred outside of the country because they aren’t considered emergency cases. But they also can’t be treated inside Syria because the necessary facilities and healthcare providers simply don’t exist anymore.

“Folks who have cancer and had their chemotherapy interrupted, all they can have is palliative medicine,” Cornish said. “And slowly, day by day, they die.”

Health workers are increasingly ill-equipped to deal with these growing problems, expert say, as their capacities are being undercut by suspicions over loyalty.

“In Syria, if you are a physician who is…’treating people from the other side’, you put your life at risk,” Sahloul said.

As humanitarian groups try to find solutions to the challenges to health and humanitarian assistance, observers appear united in their calls to the international community to ramp up pressure on both sides to stop hospital and medical staff attacks and to have more respect for international humanitarian standards.

Geneva Call, a non-governmental organisation in Geneva that focuses on engaging non-state actors in international humanitarian law, released several short video spots promoting respect for international humanitarian standards. One of the videos’ titles was “Respect and Protect Medical Personnel and Objects”.

Tom Bollyky suggested that treating these violations with more seriousness in the International Criminal Court– and recognising the international community’s responsibilities in combating them – would be a step in the right direction.

“You have seen a surge in these attacks, but you have not seen a surge in the indictments being brought against the people behind them,” he said. “The international legal system is not known for being expeditious, but it would be a form of real condemnation.”