Taking Aim at Neutrality: Upholding the Principle of Medical Non-interference in Syria

“Syria is the most dangerous place in the world to be a doctor,” claims a recent report by the Johns Hopkins Bloomberg School of Public Health that compiled the findings of dozens of interviews with medical professionals in Syria. Doctor Zaher Sahloul, President of the Syrian American Medical Society, summarized this danger in the following statement: “What we are witnessing [in the Syrian conflict are] the systematic and deliberate attacks on medical professionals by the government. Doctors are harassed, detained, tortured and killed just because they are performing their humanitarian and professional duties.” Clearly, Syrian civilians are not the only victims of the Syrian conflict, and as Dr. Sahloul illustrates, medical practitioners have been the tragic target of frequent attack. Though there are few substantiated figures that illustrate the civilian death toll since the beginning of the conflict, mainstream media outlets report that as of 2014, over 3,500 children have died as a direct result of the conflict in Syria. Before the start of the Syrian Uprising, the nation’s health care was well regarded in the Arab world, and the population had an average life expectancy of 76 years. The average citizen today is expected to live until 55. Caught in the crossfire of a violent conflict between the Syrian government, opposition forces, and the Islamic State, medical professionals fill a crucial humanitarian role that is more challenging than ever before. While the political and geostrategic interests of parties in the Syrian conflict certainly underlie the violence in Syria, this paper does not seek to address the complex dynamics between the Assad regime, opposition groups, and the Islamic State, which have dominated coverage in the mainstream media. Rather, the goal of this paper is to critically examine the Syrian regime’s violations of medical neutrality since the start of the conflict in March 2011.

Both within the United States and at the international level, efforts have been made to uphold the principle of medical neutrality. The principle of medical neutrality originates from the Geneva Convention of 1864, during which leaders of twelve European countries convened to recognize the neutrality of medical personnel during wartime, as well as to establish neutrality for hospitals and ambulances marked with the sign of the recently established Red Cross. Article Five of the first Geneva Convention extends the right of neutrality to any “inhabitant of a country” who offers medical assistance or shelter to a wounded combatant. Three subsequent Geneva Conventions followed the Convention in 1864, expanding upon the doctrine of humanitarian protection.

Today, violations of medical neutrality constitute a war crime under the Geneva Convention. Yet, as an international norm, the principle has had minimal influence mitigating violence in the Syrian conflict. The presumption that it is upheld in all conflicts likely explains why conversations about medical neutrality violations have not been at the forefront of media coverage, relative to other debates surrounding the Syrian conflict—the debate on the use of chemical weapons being one example. The repeated violation of medical neutrality in the Syrian conflict evokes pressing concerns about the utility of international intervention.

On the international stage, beyond the legal precedent of medical neutrality established in the first Geneva Convention, several international nonprofit organizations and transnational advocacy networks have made efforts to uphold medical neutrality. For medical workers in Syria, the constraints of overcrowded and understaffed hospitals compound the stress of near-constant threats of violence, overwhelmingly from the Syrian regime. Physicians for Human Rights (PHR), a nonprofit advocacy organization that is committed to mobilizing health professionals and the public for the protection of human rights, released a report in March 2015 that documented the killing of 610 physicians in Syria since the beginning of the conflict in 2011. Doctors Without Borders (Médecins Sans Frontières), has been similarly active in working to realize the Geneva Convention’s vision of medical neutrality. By highlighting the systematic bombing of hospitals and destruction of ambulances, Human Rights Watch has also drawn attention to blatant transgressions of medical neutrality in Syria.

In the United States, members of Congress have made legislative efforts to hold other nations accountable for maintaining medical neutrality. The Medical Neutrality Protection Act of 2011, introduced to the United States Congress by Representative Jim McDermott (D-WA), requires that the United States Secretary of State annually update a list of foreign governments that have engaged in violations of medical neutrality and formally notify each government implicated. In the bill, violations of medical neutrality are thoroughly defined, including (but not limited to) militarized attacks on health care facilities, providers, or individuals in the course of receiving medical treatment and destruction of medical supplies.

Doctors, surgeons, nurses, and paramedics are among the many kinds of medical practitioners who may even face greater risk than Syrian civilians because of the nature of their profession. The United Nations Office of the High Commissioner for Human Rights (OHCHR) released a report that substantiated the anecdotal evidence of the violent targeting of medical practitioners. According to the report, the breaches of medical neutrality in Syria have reached alarming levels, most notably through the targeting of medical personnel and hospitals as a “tactic of war [for] military objectives.”

Yarmouk, a besieged, unofficial Palestinian refugee camp in Damascus, has recently been the site of violations of medical neutrality by both Islamic State and Syrian regime forces. Though the report from OHCHR indicates that hospitals in Yarmouk camp were shelled in 2012, the Syrian government is also guilty of violating medical neutrality by less immediately violent means. For instance, the OHCHR report claims that the regime is guilty of denial of medical access to civilians on the basis of “real or perceived political and sectarian grounds.” The siege of Yarmouk has also resulted in deplorable living conditions for the 18,000 residents, causing United Nations Secretary General Ban Ki-Moon to describe the city as “the deepest circle of hell.” Both the Islamic State and the Syrian military are responsible for blocking the transmission of vital humanitarian aid, including medical treatment and supplies, to its starving and sick residents.

While the prevailing number of attacks against medical practitioners are launched by the Assad regime, Syrian medical staff working in government hospitals also face a fear of abduction by anti-government groups who might consider them to be aiding the enemy and loyal to the state. A search for the hashtag, #DefendDoctors on Twitter reveals a collection of stories of Syrian doctors on a government “wanted list” for providing medical care to patients to any members of regime opposition groups. In other words, medical practitioners face being consistently targeted and scapegoated by both sides.

PHR also claims that of the 610 medical personnel who were killed in the last four years, the Assad regime perpetrated the killings 97 percent of the time. PHR has compiled the attacks against medical personnel in Syria since the start of the Syrian Uprising in 2011. According to PHR, 88 percent of the 233 attacks on hospitals since March 2011 have been made by government forces, using various methods ranging from barrel bombs to arson. Erin Gallagher, Director of Emergency Investigations and Response at PHR, claims that the figures are actually conservative estimates based on verified reports, suggesting that the true mortality rate is much worse. The undeniably systematic targeting of hospitals by government forces is evidenced by reports of particular hospitals that have been repeatedly bombed, as well as ones in remote areas with no nearby alternative targets. Furthermore, the hospitals that have suffered the greatest number of attacks have been located within Syrian opposition strongholds, including Rif Damashq, Homs, and Aleppo.

Both in anticipation of targeted bombings, as well as due to the scarcity of hospitals, many medical practitioners throughout Syria now operate in field hospitals located in basements, homes, factories, and other hidden facilities where the risk of attack is lower. Shoddily assembled field hospitals lack vital equipment such as CT scanners, intensive care units, and ultrasound machines to carry out the most basic of procedures. The security situation in Syria has eroded so drastically that many residents expect hospitals to be bombarded, and as a result do not seek proper medical treatment.

With dwindling numbers of medical professionals still living in Syria, the roles and responsibilities of those who remain in the country have become increasingly onerous. Data from the World Health Organization indicate that before the civil war be, an average of 1.5 physicians served every 1000 people in the national Syrian population. By comparison, a study conducted by the Bloomberg School of Public Health at Johns Hopkins University reports that in 2014, “only 13 surgeons and a total of about 30 doctors serve[d] 300,000 people in Aleppo,” marking a near 150 percent decline in the current density of physicians in Aleppo (what was once the most populous city in Syria). This figure confirms that the constant threat of violence has come at a serious cost to anyone living in Syria: the exodus of medical practitioners from the country. The following accounts shed light on the reality on the ground for doctors and the often overwhelming circumstances in which they operate.

A recent op-ed in the New York Times by a Syrian surgeon named Abdel presents a harrowing story of his daily routine as a medical practitioner. Abdel recalls assisting a man whose leg had been severely fractured. The man, along with two other patients, were placed inside of an ambulance to be taken 90 minutes away to the Turkish border at a safe facility that promised better medical care.While they were en route to the border, a barrel bomb landed and detonated next to the ambulance, killing all passengers except for the paramedic.

Abdel requested anonymity for the interview, for he, too, is being targeted by the government for the medical services he has offered to the wounded. Another New York Times article in March of 2013 chronicled the experiences of violence and targeted attacks that practitioners have experienced since the outset of the war. In the article, Aleppo-based urologist, Dr. Yassir Darwish, reports that while imprisoned by the Syrian government, he experienced frequent interrogations involving torture. He was originally arrested for sneaking medicine and treating patients in field clinics. Dr. Hassan Julaq, an orthopedist, reported that torture in a prison in Damascus included being forced to walk constantly bent over, which has resulted in long term back damage. Many detained health workers have similarly reported being tortured by the Syrian secret police force. Yassir and Hassan’s experiences are by no means unusual—they are emblematic of systemic detention and torture of doctors by the Syrian regime.

Medical practitioners in Syria today are resilient, risking their lives and facing prison, torture and targeted bombings to uphold humanitarian commitments to health care amidst an unbridled civil war and regional conflict. Yet, beyond the media coverage referenced here, the discussion on the violation of medical neutrality in the Syrian conflict is relatively limited. This is not for lack of narratives, as demonstrated by the stories of Abdel and Dr. Darwish presented in the New York Times. Nearly every doctor that remains in Syria today is living under serious threat of sustained violence and persecution. The doctors remaining in Syria are fully aware that their sustained presence maintains the sole means by which civilians can continue to endure unchecked violence. Yet countless practitioners have fled and will continue to do so, as the preservation of their own lives depends on it. •