Physicians for Human Rights ’s Medical

October 2014 Community Under Assault

For the most recent version, see physiciansforhumanrights.org/ syria-fact-sheet

“The targeting of the medical community in Syria has reached epic proportions. The insidious attacks on medical professionals, facilities, and transport have devastated the country’s public health infrastructure, exacerbating an already overwhelming crisis.” - Donna McKay, PHR executive director

Introduction Since the war began in Syria in 2011, hospitals, field clinics, ambulances, and vehicles transporting medicine and medical supplies have been deliberately targeted for destruction. While government forces have been largely responsible, the self-declared Islamic State and various anti-government armed groups have also carried out attacks. Medical personnel have also been arrested, tortured, executed, and disappeared. These crimes against the principle of medical neutrality – which ensures safe access to medical facilities, protects health care workers and their patients, and allows medical workers to provide unbiased care – have compounded the suffering of civilians and hastened the devastation of an already fragile health care system.

Table of Contents 1 Introduction 2 Destruction of Medical Facilities 3 Loss of Medical Personnel 4 Resulting Health Consequences 5 References

Syrian doctors treat a wounded man in a field hospital in the city of Qusayr. Photo: Antonio Pampliega/AFP/Getty Images

phr.org Syria’s Medical Community Under Assault: October 2014 1 As of May 2014, there were only 40 doctors serving the population of 2.5 million in .

Destruction of PHR has documented 195 attacks on 155 separate medical facilities between March Medical Services 2011 and the end of August 2014.1

As of June 2014, the World Health Organization (WHO) and the Syrian Ministry of Health reported that only 40 percent of public hospitals were fully functioning, 34 per- cent were partially functioning, and 23 percent were not functioning.2

Aleppo Governorate: • In July 2012, Aleppo’s blood bank was bombed.3 Since then, the 2.5 million people living in the city of Aleppo have been without blood supply or blood bags. 4 • On August 23, the Omar bin Abdulaziz Hospital in Aleppo hospital declared a strike in protest against a conflict between doctors and an armed fighter with Harakat Hazam, as well as prior incidents of harassment and threats by various armed groups. The armed groups agreed to stop all harassment and the strike ended several days later.5

Damascus Governorate: • As of June, the only functioning hospital serving the 18,000 people besieged in , was the Red Crescent-run Palestine Hospital. The other two main hospitals were destroyed by fighter jets and artillery.6 • As of March, Amnesty International reported that the same hospital hosted the camp’s only pharmacy that was still in operation. Prior to the conflict, there were be- tween 100 and 120 pharmacies in the camp.7 The Palestine Hospital has been attacked by shelling and rockets on at least two separate occasions. In Rif Dimashq, 24 out of 44 private hospitals, 3 out of 6 public hospitals, and 54 out of 176 health centers are out of service.8

Raqqa Governorate: • National Hospital was the only hospi- tal with dialysis services in the governorate, serving 200 patients.9 In March 2014, the hospital’s kidney department was aerially bombarded by government forces, and the dialysis center was destroyed.10 • In Raqqa city in August, only five of the seven main health centers and hospitals in operation before the conflict were function- ing at a limited capacity. The main factors impeding the facilities’ functionality are lack of medical equipment, medicine, and medi- cal staff.11 Since the beginning of the crisis, 13 out of UNRWA’s 23 primary health centers have been closed due to the conflict.12 Remains of an opposition field hospital in Qusayr in Syria’s central Homs province. Photo: AFP/Getty Images

phr.org Syria’s Medical Community Under Assault: October 2014 2 560 medical personnel have reportedly been killed since the beginning of the conflict.

Loss of Medical Personnel As of August 31, 2014, 560 medical personnel had reportedly been killed since the begin- ning of the conflict, including 183 doctors, 110 nurses, 107 medics, and 51 pharmacists, among others.13

Little to no mental health services are available, as most mental health professionals have left the country.14 Since Ibn Khaldun mental hospital in Aleppo was destroyed in December 2012, only two psychiatric facilities remain – one in , the other in Rif Dimashq.15

As of December 2013, an estimated 15,000 doctors had fled the country.16 • As of May 2014, there were only 40 doctors serving the population of 2.5 million in Aleppo, which had 2,000 doctors before the war began; only 10 to 15 surgeons were available to perform the necessary 1,500 surgeries in the city each week.17 As of March 2014, the opposition-controlled parts of the city had an estimated 10 to 12 general surgeons, three to five orthopedic surgeons, and fewer than 10 internal medicine specialists.18 • While Eastern Ghota had 1,000 doctors before the conflict broke out, an estimated 30 remained as of December 2013.19

Targeting of Humanitarian As of August 2014, 45 Red Crescent workers (38 Syrian Arab Red Crescent staff mem- Aid Workers bers and volunteers and seven Palestine Red Crescent Society staff members and volun- teers)20 had died while carrying out humanitarian work in Syria, all clearly displaying the red crescent emblem.21

On January 2, 2014, five MSF staff members were taken from their house in northern Syria. Three of the staff members were released on April 4, and the remaining two were released on May 14. The abduction forced MSF to permanently close one of its hospitals and two health centers in the Jabal Akkrad region.22

As of August 2014, 28 UN national staff members remained in detention or were miss- ing (27 from UNRWA and 1 from UNDP). An additional 14 UN staff members have been killed since the start of the conflict.23

In March, Amnesty International reported that at least 12 medical workers have been arrested in besieged Yarmouk camp, six of whom remain unac- counted for; one allegedly died from torture and ill-treatment. Many other medical workers have left the camp in fear of arrest.24

Access across northeastern Syria, controlled by the self-declared Islamic State (IS), also called ISIS or ISIL, continues to be difficult. Despite overall increases in food aid delivered around the country, WFP reported that in July and August, no food reached Raqqa (with 284,000 targeted recipients), and aid sent to Deir ez Zor and Hassakeh was only sufficient for 20 percent of those in need.25

On August 6, an 18-truck WFP convoy en route from Deir ez Zor to Raqqa was attacked by an unknown group. Two truck drivers were killed, two 26 A doctor carries a wounded boy at a hospital in Syria’s were injured, and the contents of four trucks were damaged or destroyed. northern city of Aleppo, who was injured when a shell, released by regime forces, hit his house. Photo: ARIS MESSINIS/AFP/GettyImages phr.org Syria’s Medical Community Under Assault: October 2014 3 9,500 Syrians are displaced each day.

Resulting Health Syria now has one of the largest and fastest evolving internal displacement crises world- Consequences wide, with 6.5 million internally displaced people.27

According to the Internal Displacement Monitoring Center, 9,500 Syrians are displaced per day.28

As of August 2014, the number of people in need of humanitarian assistance had reached 10.8 million, with up to 4.7 million of these individuals residing in areas that are difficult or impossible for humanitarian actors to reach.29

Approximately 241,000 people remain in besieged areas. • Between July 22 and August 18, UN assistance only reached two besieged areas: Yar- mouk and Moadamiya. Food was delivered to 2.5 percent of the besieged populations (6,060 people), while non-food items reached 1.8 percent (4,520 people) and medi- cines reached 10.5 percent (15,100 people).30 • This was the first time medical supplies, with the exception of vaccines, were able to reach Moadamiya and Yarmouk since October 2012 and December 2012, respec- tively.31

Despite the adoption of UN Resolutions 2139 and 2165 aimed at improving aid and humanitarian access, the protection situation has worsened. • The UN Secretary General reported that July and August 2014 were two of the deadli- est months since the conflict began, with over 1,000 civilian deaths in each.32 • The WHO has reported a dramatic increase in injuries – averaging 25,000 each month as of August – which combined with a shortage of medical supplies and power cuts, have left hospitals unable to cope with the demand for surgical and clini- cal treatment. This has led to an increase in the number of reported complications, such as septicaemia, gangrene, organ failure, and/or deaths.33

Outbreak of Disease

Syria is facing its first polio outbreak since 1999, with 140 reported cases of acute flacid paralysis (AFP).34 The WHO had confirmed 36 polio cases as of July 2014.35 However, Dr. Raafat al-Assaad of the Mohassan Field Hospital reported that there are over 70 cases of polio and 25 cases of tuberculosis in Deir ez Zor alone.36

Typhoid and hepatitis A are reportedly increasing, especially in ar- eas with high levels of violence. Water contamination in the Euphra- tes river, heavy violence, damaged water infrastructure, hot weather, overcrowded shelters, and frequent power cuts, among other issues, have made Deir ez Zor governorate more susceptible to the spread of communicable diseases. Of the 2,600 WHO-reported typhoid cases between January and mid-July of 2014, approximately 76 percent (or 2,000 cases) were in Deir ez Zor.37 An injured Syrian woman rides in the back of a van as it arrives at hospital following an air strike by regime forces in Aleppo. Photo: TAUSEEF MUSTAFA/AFP/GettyImages

phr.org Syria’s Medical Community Under Assault: October 2014 4 Syria is facing its first polio outbreak since 1999.

Limited Supplies and Approximately 24,000 people remain in areas of Moadamiya that are besieged by gov- Medications ernment forces. Although an inter-agency convoy gained access in mid-July to deliver food supplies, six months’ worth of medicine and medical supplies were excluded from the convoy.38 On July 28, the WHO and SARC delivered five metric tons of medical assistance, only sufficient for two months, to the only functioning health center in the town. This was the first medical assistance – with the exception of vaccines – to reach the town since October 2012. Supplies included antibiotics, chronic disease medicines, and multivitamins for children.39

Health facilities in Deir ez Zor city suffer from a chronic lack of supplies and staff. A July assessment found that the population faces “life-threatening conditions causing high levels of suffering and irreversible damages to health, which can result in deaths if no humanitarian assistance is provided.” The public health system is reportedly operating at 5 percent of the required capacity.40

Between April and June of 2014, the WHO procured and distributed essential medical supplies and life-saving medicines for trauma and emergency obstetric care. Only 28 percent of these were distributed to territory controlled by the opposition,41 despite the fact that 37 percent of people in need live in these areas.42

There is a dire need for anesthetics, blood, blood bags, antibiotics, infant vaccines, hospital beds, electricity, fuel, radios, and nurses.43 Insufficient access to safe blood is increasingly exposing the Syrian population to the risk of blood-borne diseases such as hepatitis B.44

In July, the United Nations Population Fund estimated that 2.7 million women are in need of reproductive health services in Syria.45

Daraa and Rif Dimashq governorates face acute shortages of life-saving treatments and basic medical supplies. Although antibiotics and WASH supplies have been recently delivered, access to medical treatment, health services, and equipment (including for surgical interventions) needs to be improved.46

Damage to pharmaceutical plants and the economic impact of the conflict have resulted in a critical shortage of medicines and medical supplies, including for non-communi- cable diseases such as diabetes, hypertension, asthma, epilepsy, and cancer. As of De- cember 2013, Syria was estimated to have an annual drug shortage of priority medicines equivalent to $468 million.47

As of August, availability of safe water supplies was one-third of pre-crisis levels, and one-third of water treatment plants were no longer functioning.48 As of September, three of four water pumping stations in Aleppo city have been shut down, affecting over two million people in both government- and opposition-held neighborhoods.49

References* 1. www.phr.org/syria-map 2. http://www.emro.who.int/images/stories/syria/documents/Snapshot_MoH_Public_Hospitals_2ndQ_190814.pdf?ua=1 3. http://www.nybooks.com/blogs/nyrblog/2013/nov/03/syria-assault-doctors/ 4. http://reliefweb.int/sites/reliefweb.int/files/resources/Aleppo%20Assessment%20Report.pdf 5. Field source, Skype correspondence with Physicians for Human Rights, September 4, 2014. 6. http://www.ipsnews.net/2013/06/in-besieged-refugee-camp-syrian-medics-struggle-to-provide/ 7. http://www.amnesty.org/en/library/asset/MDE24/008/2014/en/c18cfe4d-1254-42f2-90df-e0fce7c762fc/mde240082014en.pdf 8. http://www.acaps.org/reports/downloader/part_i_syria_apr_2014/79/syria 9. http://sn4hr.org/public_html/wp-content/pdf/english/Kidneys%20patients%20die%20in%20Raqqah%20governorate.pdf 10. http://syrianewsdesk.com/en/2014/03/12/news-regime-air-raid-targets-al-raqqas-national-hospital 11. http://reliefweb.int/sites/reliefweb.int/files/resources/SYR_ArRaqqa_UrbanProfile_FoodHealthandWater_Aug2014.pdf 12. http://www.unrwa.org/sites/default/files/2014_syria_emergency_appeal.pdf

phr.org Syria’s Medical Community Under Assault: October 2014 5 References (cont.) 13. www.phr.org/syria-map 14. http://www.emro.who.int/emergency/eha-news/syria-sitrep.html 15. http://www.emro.who.int/images/stories/syria/documents/SituationReport_20140801.pdf?ua=1 16. http://reliefweb.int/sites/reliefweb.int/files/resources/SINA_EN_Final.pdf 17. http://www.acaps.org/reports/downloader/part_i_syria_july_2014/89/syria 18. Field source, Skype correspondence with Physicians for Human Rights, March 24, 2014. 19. Field source, interview by Physicians for Human Rights, Amman, , December 5, 2013. 20. https://www.icrc.org/en/document/syria-sarc-first-responders-need-be-respected#.VBxihvldXg8 21. https://www.icrc.org/eng/resources/documents/news-release/2014/08-19-syria-call-respect-for-humanitarians.htm 22. http://www.doctorswithoutborders.org/article/five-msf-staff-held-syria-released 23. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 24. http://www.amnesty.org/en/library/asset/MDE24/008/2014/en/c18cfe4d-1254-42f2-90df-e0fce7c762fc/mde240082014en.pdf 25. http://www.acaps.org/img/reports/b-snap_ras_brief_3_september_2014.pdf 26. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 27. http://www.internal-displacement.org/assets/publications/2014/201405-global-overview-2014-en.pdf 28. http://www.internal-displacement.org/assets/publications/2014/201405-global-overview-2014-en.pdf 29. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 30. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 31. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 32. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 33. http://www.emro.who.int/images/stories/syria/documents/SituationReport_20140801.pdf?ua=1&ua=1 34. http://www.nybooks.com/articles/archives/2014/mar/06/truth-about-polio-syria/?pagination=false 35. http://www.acaps.org/reports/downloader/part_i_syria_july_2014/89/syria 36. http://www.syriadeeply.org/articles/2014/05/5499/conversations-doctors-deir-ezzor-polio-infectious-diseases-return/ 37. http://www.acaps.org/reports/downloader/brief_august_2014/94/syria 38. http://reliefweb.int/sites/reliefweb.int/files/resources/Humanitarian%20Bulletin%20Syria%20Issue%2049.pdf 39. http://www.un.org/en/ga/search/view_doc.asp?symbol=S/2014/611 40. http://reliefweb.int/sites/reliefweb.int/files/resources/REACH_SYR_Factsheet_DeirEzZorCity_27082014.pdf 41. http://www.emro.who.int/images/stories/syria/documents/WHO_Donor_Update_Q2.pdf?ua=1 42. http://www.scribd.com/doc/231412280/OCHA-Population-in-Need 43. Field source, interview by Physicians for Human Rights, Amman, Jordan, December 5, 2013. 44. http://www.emro.who.int/images/stories/syria/documents/SituationReport_20140801.pdf?ua=1 45. http://www.unfpa.org/webdav/site/global/shared/documents/Emergencies/UNFPARegionalSitRep1-31July2014_23.pdf 46. http://www.emro.who.int/syr/syria-news/medical-aid-2014.html 47. http://reliefweb.int/sites/reliefweb.int/files/resources/2014_Syria_SHARP.pdf 48. http://www.acaps.org/reports/downloader/brief_august_2014/94/syria 49. http://www.sos-childrensvillages.org/news-and-stories/news/aleppo-water-shortage-emergency-sos-response

*The ongoing conflict inside Syria has made the verification of statistics around the crisis particularly challenging. However, Physicians for Human Rights has cross-referenced information and sources whenever possible in order to provide the most accurate and up-to-date numbers and statistics.

Physicians for Human Rights (PHR) uses medicine and science to document and call attention to mass atrocities and severe human rights violations. PHR was founded in 1986 on the idea that health professionals, with their specialized skills, ethical duties, and credible voices, are uniquely positioned to stop human rights violations. PHR’s investigations and expertise are used to advocate for persecuted health workers, the prevention of torture, the investigation of mass atrocities, and holding those who violate human rights accountable.

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