Physicians for Abandoned Human Rights A Case Study on Health Care in November 2015

A medic carries a wounded child following a government airstrike on the opposition-held al-Maghair district of Aleppo. EmbargoedPhoto: Karam al-Masri/AFP/Getty DraftImages EmbargoedAbout Physicians Draft for Human Rights

For nearly 30 years, Physicians for Human Rights (PHR) has used science and medicine to document and call attention to mass atrocities and severe human rights violations.

PHR is a global organization founded 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 and medical facilities under attack, prevent torture, document mass atrocities, and hold those who violate human rights accountable.

Acknowledgements

This report was written by Elise Therapeutics, Inc., and professor PHR is grateful to Palantir Baker, program associate at PHR, of medicine in the Department Technologies for their continued and Michele Heisler, MD, MPA, of Medicine and Heart Institute support and the donation of their PHR volunteer medical advisor, at Cedars Sinai Medical Center; Gotham platform, through which PHR board member, professor of and Donna Shelley, MD, MPH, PHR is able to integrate, analyze, internal medicine and of health associate professor of medicine and visualize data on attacks on behavior and health education and population health, vice chair health care. Palantir’s tools have at the University of Michigan for research, and co-director of the supported the research and analysis Medical School. Section on Tobacco, Alcohol and included in this report. PHR is also Drug Use in the Department of grateful for The Carter Center’s This report benefited from review Population Health at the New York collaboration and data sharing by PHR leadership and staff, University School of Medicine. on conflict events, which help including Widney Brown, director contextualize PHR’s documentation of programs, DeDe Dunevant, PHR intern Trip Eggert assisted in within the broader context of the director of communications, and the report’s production. Syrian conflict. Donna McKay, executive director. PHR is deeply indebted to the Syrian The research protocol for this This report also benefited from doctors who were willing to share report was approved by PHR’s external review by Deborah D. their experiences with us. PHR is Ethics Review Board. Ascheim, MD, PHR board chair and also grateful to the Syrian American chief medical officer of Capricor Medical Society for the invitation to its annual conference in Gaziantep and for its continued partnership and support. Aleppo Areas of Control Map

Kilis Turkey Syria

Azaz

M4

217 214

20 62 Nubl

Reyhanli

Aleppo 4 M45 60 5

M4

Idlib

Source: The Carter Center Key using Palantir Technologies Government Control Kurdish Control Opposition Control Islamic State Control

Table of Contents

2 Introduction 20 Conclusion 4 Background on Syria and 21 Epilogue the Conflict in Aleppo 22 Recommendations 7 Methodology and Limitations 23 Endnotes 8 Findings

Physicians for HumanEmbargoed Rights phr.org Draft Introduction “You must be safe to save others … If you kill the physician or destroy Embargoed Draftthe hospital, the medicine doesn’t benefit any people.”1 Dr. D, a urologist working in a trauma hospital in Aleppo

A barrel bomb falls from the sky, The doctors, nurses, medics, and other tumbling through the air toward civilians health workers in Syria’s opposition- Rescue workers cover a corpse in markets and homes. It shatters when controlled areas have been abandoned under the debris outside Dar al-Shifa it hits the ground. Shrapnel and nails by the international community and UN hospital in Aleppo. filling the barrel fly in all directions, Security Council. They cannot fathom Photo: Francisco Leong/AFP/ causing catastrophic injuries. Minutes how the world can stand passively by Getty Images later, after the first responders and and watch as a quarter of a million medics have rushed to the scene to people die, millions more are displaced, provide emergency aid, another bomb and civilian homes and workplaces are falls – targeting them. This is a double obliterated. They are left standing in tap strike. Those left standing transport their barren, makeshift hospitals with the injured and dying to a nearby nothing but sandbags protecting them hospital, where doctors race to save from the next airstrike, wondering how lives knowing at any moment they could much longer they have left to live. be bombed. When the last casualty is They know that as long as the world’s treated, it is time to count the dead. indifference continues, the odds are Doctors and first responders pick up against them. body parts and wonder whose mothers, fathers, and children the mangled limbs Welcome to Aleppo. belong to.

2 Aleppo Abandoned: A Case Study on Health Care in Syria “I never expected to see doctors tortured, to see what we saw. It’s probably best that we didn’t know this would happen. Otherwise, we may not have started the revolution.”2 Dr. M, an orthopedist working for an organization supporting health care in Aleppo

The conflict in Syria is well into its While the self-declared Islamic and thousands of their patients have fifth year, and as of October 2015, State (IS), also called ISIS or ISIL, has lost their lives. Health workers in Aleppo Physicians for Human Rights (PHR) has grabbed headlines with its exhibitionist understand the UN Security Council’s documented the deaths of 687 medical violence, the Syrian government failure all too well. They live with the personnel and 329 attacks on medical has systematically violated every reality of disappeared colleagues and facilities. The Syrian government is international law aimed at protecting hospital attacks every day. Yet they have responsible for nearly 90 percent of civilians. Its strategy is to bomb its not given up hope, and they continue these attacks.3 Each attack, whether the citizens into submission – destroying to ask for one simple thing: an end bombing of a hospital or the detention hospitals, markets, and mosques in to the attacks on hospitals, medical and torture of a doctor for providing order to punish the opposition and its personnel, patients, and civilians. If the health care, is a war crime. Given the supporters for their political views and international community will enforce systematic nature of these attacks make life unbearable outside of the these protections, as mandated by by Syrian government forces, these areas it controls. The Syrian government international law, Aleppo’s medical violations constitute crimes against has forced health workers to risk their workers are confident their colleagues humanity. The Syrian government’s lives to save others and left its well- who fled will return, and together they ongoing assault on health care is one established health care system – one can begin rebuilding their country’s of the most egregious the world has of the best in the region – in ruins that health care system. But first, the attacks ever seen. will take decades to rebuild. It has also must stop. compelled millions of civilians injured in International humanitarian laws (IHL) bombardment on their homes, markets, Syrian forces must immediately were negotiated more than 150 years mosques, and schools to weigh the stop attacking medical facilities and ago and have since been ratified by risks of dying from treatable conditions personnel in Syria. If they do not and 196 countries, including Syria, in an versus dying in a hospital attack while these war crimes continue, the UN attempt to protect civilians in conflict. seeking life-saving care. Security Council must implement further They prohibit parties to conflict from measures (as prescribed in Resolutions targeting non-combatants and require This report focuses on the state of 2139 6 and 21657) to ensure that the that special measures be taken to health care in eastern Aleppo city4 – the Syrian government and all other prevent harm to civilians or civilian city hit hardest by these attacks5 – and parties to the conflict end all unlawful objects. In addition to these protections, tells a story of courage and resilience in attacks on civilians and respect medical medical personnel and facilities are the face of tremendous human suffering neutrality, the principle under IHL that awarded even greater protection under and loss. PHR’s findings illustrate that health care is protected and must be the Geneva Conventions. IHL requires the unlawful attacks have significantly provided impartially. that all parties protect and ensure degraded Aleppo’s health care system; the functionality of medical facilities, more than two-thirds of the hospitals no The consequences are clear: failing to transport, and personnel; all parties longer function and roughly 95 percent stop attacks on medical professionals protect and ensure unbiased treatment of doctors have fled, been detained, or and infrastructure has resulted in and for both wounded civilians and killed. However, the remaining medical will continue to result in devastating combatants; and that medical personnel personnel have persevered and manage health outcomes for civilians living in provide impartial care to both civilians to provide health care in the midst of conflict zones. Syria’s unprecedented and wounded combatants, in keeping a horrific war, despite minimal access assault is not only disrupting emergency with medical ethics. States established to equipment and medication. They aid, but also depriving communities these laws because they agreed that have learned to rebuild hospitals after of routine health care and threatening anyone injured in a conflict – civilians their own have been bombed and their very capacity to survive. It will take and combatants alike – should have provide lifesaving care without adequate decades to rebuild Syria’s health care guaranteed access to health care in a personnel, medications, supplies, and system, but the effects go far beyond safe space. equipment, while risking their own lives. the country’s borders. The longer This report also points to the failure the UN Security Council continues to of the international community to shirk its responsibility of maintaining stop these violations. The UN Security international peace and security, the Council has failed to do its duty for greater the chance these violations more than four years, and, as a result, will become the new normal in armed hundreds of Syrian medical personnel conflicts around the world.

Physicians for HumanEmbargoed Rights phr.org Draft3 BackgroundEmbargoed on Syria and the Conflict inDraft Aleppo

Syrian rescue workers carry body parts in a shroud following a reported barrel bomb attack by Syrian government forces on the opposition-held al-Shaar district of Aleppo. Photo: Karam al-Masri/AFP/ Getty Images

Background on Syrian Conflict promises of reform, it increased – bombing markets, schools, mosques, repression and deployed security forces and hospitals and besieging opposition- On March 15, 2011, five young Syrian to crush protests. controlled towns. This brutality, men gathered in ’s central combined with the country’s power Hamidiya market and shouted, “We On July 29, 2011, seven Syrian military vacuum, encouraged more Syrians to sacrifice our blood and souls for officers defected and announced the form armed groups with their own you, Syria!”8 These men were just a formation of the Free agendas, many founded upon Islamist few of the hundreds of people who (FSA), the first anti-government armed ideologies. By early 2014, extremist stood up that day and demanded group aimed at overthrowing the Assad groups such as IS had gained traction, the release of 15 children who had government.9 The opposition gained and the Syrian civil war had grown into been arrested and tortured for spray- momentum as military and government a sectarian war. painting anti-government graffiti on defectors joined the FSA’s local militias their school’s wall in , southern and took control of neighborhoods and Now, four and a half years into the Syria. In the coming months, hundreds towns sympathetic to their aims.10 By conflict, more than 12 million Syrians of thousands of Syrians joined peaceful the end of 2011, Syria was engulfed in are displaced from their homes, an demonstrations demanding human a protracted conflict, bifurcated estimated 240,000 have been killed, rights and democracy from the between government- and opposition- and civilian deaths continue to mount.11 authoritarian government of President controlled territories. Fighting is escalating among opposition Bashar al-Assad. They were part of a groups, and all parties to the conflict are movement sweeping through the region The conflict intensified over the next violating human rights and humanitarian that began with Tunisia’s successful year as opposition groups increased in law. Yet the UN Security Council remains and largely peaceful revolution. But size, strength, and control. The Syrian paralyzed by politics. Left with no other the Syrian government did not cede government responded by ignoring option but to be killed at home or live to protesters; while trumpeting false IHL and deliberately targeting civilians in chronically underfunded refugee

4 Aleppo Abandoned: A Case Study on Health Care in Syria camps along their country’s border, significant violence to the city.15 Over improvised explosive devices dropped Syrians are now fleeing. Hundreds of the next five months, public protests from helicopters.18 When this assault thousands have chosen to risk their lives and discontent with the government first began in late 2013, Aleppo was at sea in the hope of reaching Europe, increased, and opposition fighters still densely populated, and a single contributing to the largest refugee crisis seized territory from government barrel bomb falling on a residential area since World War II.12 forces in the areas surrounding could injure 100 people. But intensified Aleppo. Finally, on the night of July attacks caused an exodus from the city, Among the list of egregious IHL 19, approximately 6,000 opposition and months into the barrel bombing violations is the Syrian government’s fighters invaded Aleppo from the city’s campaign, each attack took a smaller systematic assault on medical personnel northern and eastern countryside human toll.19 and facilities, the scope and scale of and gained control of eastern and which is unprecedented since the southwestern neighborhoods.16 The By August 2014, barrel bomb attacks adoption of the modern Geneva Syrian government responded to the slowed to just a few each day and Conventions. Attacks have continued opposition (which was armed with remained at these lower levels until unabated since the start of the conflict rifles and machine guns) by firing April 2015. Many residents who had and in recent months have increased in mortar shells, launching rockets from previously fled the city returned during number. PHR has already documented helicopters, and sending additional this period, as decreased attacks inside over 90 attacks on medical facilities troops from other parts of the country the city coincided with increased since the start of 2015, making it the to defend the city’s western half. airstrikes in parts of rural Aleppo worst year yet for attacks on hospitals Government forces did not send ground governorate (including by U.S.-led in Syria. Aleppo (Syria’s most populous troops to retake lost neighborhoods, coalition forces) and the growing threat city, located on a strategic trading but strafed them with helicopters and of IS east of the city. Over the summer route between the Mediterranean Sea warplanes.17 Despite being outgunned, of 2014, IS forces advanced west from and Mesopotamia, which served as the opposition forces remained in their stronghold in governorate a melting pot for many cultures and control of a significant part of the city. and took over villages only 30 miles religions) is one of the areas hardest north of Aleppo. Many residents of hit by these attacks, with 45 attacks on Over the next few months, fighting these and neighboring villages were medical facilities in the past three years. reached a stalemate. Government displaced to Aleppo.20 forces controlled the western half of the Timeline of Conflict in Aleppo city while opposition forces controlled The most recent period of the conflict the eastern half, and the 2.5 million has again seen more numerous attacks The revolution came to Aleppo later residents were split roughly evenly on the city. Beginning in April 2015, than to other parts of Syria. In 2011, as down the middle. Throughout this after government forces lost territory pro-democracy protests and violence stalemate, each side indiscriminately in neighboring governorate, they engulfed much of the country, Aleppo’s attacked the other – opposition forces began a renewed assault on Aleppo residents held rallies in support of the with mortar fire and government forces with barrel bombs. According to Syrian government.13 This support with rockets and missiles – in violation doctors we spoke with, this assault stemmed mainly from affluent of IHL. Government forces also targeted was even more intense than the last. western Aleppo, while lower-income civilian spaces such as schools, markets, The bombing was compounded by an eastern Aleppo quietly supported the bakeries, and hospitals. Their aim was IS advance that threatened to cut off opposition.14 simple: make living in opposition- the main supply route to Turkey and controlled areas unbearable. While some effectively besiege the city.21 While IS But the conflict eventually swept across residents fled to rural areas, to Turkey, or has not succeeded, Aleppo’s residents the country, and on February 10, 2012, even to government-controlled territory, are fearful that the situation could two car bombs were detonated outside hundreds of thousands remained. change rapidly with either an advance a military security headquarters and a by government forces from the west or police compound in western Aleppo, From December 2013 through the IS forces from the east. killing 28 military and security personnel summer of 2014, government forces and civilians and bringing the first employed a new tactic, showering Aleppo daily with barrel bombs –

Physicians for HumanEmbargoed Rights phr.org Draft5 Background on Syria and the Conflict in Aleppo continuedEmbargoed Draft

Barrel Bombs: Weapons that Terrorize and Maim

Barrel bombs are a crude, low-cost weapon made by filling empty barrels or cylinders with explosives, shrapnel, nails, and oil and dropping them from helicopters. These weapons weigh between 200 and 2,000 pounds and can decimate an entire city block. They are indiscriminate and extremely destructive, as they tumble through the air and break into thousands of fragments upon impact, resulting in an enormous blast radius. They annihilate anything and anyone in their path, tearing flesh apart and leaving just body parts in their wake. In addition to the physical destruction, barrel bombs have a tremendous psychological impact on those living in their path. There is no way to protect oneself from Syrian rescue workers look up to them; residents live in constant fear the sky in search of warplanes in the of blue skies, which often bring al-Jallum neighborhood of Aleppo, barrel bomb assaults. following a reported barrel bomb attack by Syrian government forces. Photo: Karam al-Masri/AFP/ Getty Images

Aleppo as a Case Study homes and reestablished hospitals in of the Syrian Conflict basements, and they have founded organizations to support medical care Aleppo has faced three years of in one of the most dangerous cities unrelenting attacks that have killed and in the world. PHR chose Aleppo as a maimed thousands of residents. The case study because it illustrates what city has also been under threat of siege, a dedicated and resilient medical both by Syrian government forces and community can achieve in some of IS, for much of that time. But rather the worst circumstances. The story than surrender to their murderous of Aleppo exemplifies the ingenuity government or the terrorizing tactics and resolve of the many Syrians who of IS, many of Aleppo’s residents have have chosen to stand up for human chosen to stay in their city and try to rights and international law rather than maintain their lives. They rebuilt their surrender to tyranny.

6 Aleppo Abandoned: A Case Study on Health Care in Syria Methodology and Limitations

Methodology individuals without specialized training Limitations who work for organizations supporting The findings in this report are based health care in Aleppo. Eleven of the Due to the ongoing conflict, PHR primarily on interviews conducted by medical personnel interviewed were researchers were unable to travel to PHR in Gaziantep and Kilis, Turkey from either currently working in hospitals in Syria to conduct interviews. This limited July 22 to July 30, 2015. The research Aleppo or had stopped in the past three the number and type of medical team conducted semi-structured months. They have worked at eight of personnel interviewed, primarily to interviews with 24 individuals providing the 10 hospitals currently functioning in those who were able to travel to Turkey. health care, supporting the health Aleppo. The interviewees came from 13 Medics, nurses, and other lesser-paid care system, or documenting events in organizations and coordinating bodies, health professionals are often not able Aleppo. They interviewed staff working of which 11 were Syrian-run and two to travel to Turkey as frequently and in or supporting each of the 10 currently were international. easily as doctors, and the few female functioning hospitals, the main aid physicians left in Aleppo do not travel and medical organizations supporting PHR obtained informed oral consent as much as their male colleagues. hospitals, and the leading organizations prior to each interview and written Thus PHR’s interviews with personnel documenting violations and providing informed consent prior to taking any currently working in Aleppo were health assessments in Aleppo. PHR photographs. For security purposes, limited to male doctors, dentists, and determined the number of physicians this report does not identify any pharmacists; consequently, they do not remaining in Aleppo by compiling data interviewees by given names or capture the experiences of other vitally on the number of staff at each hospital, commonly used pseudonyms. Instead, important health workers and female which PHR received from each hospital’s it refers to each individual interviewed physicians who are also risking their lives physicians or organizational staff. PHR by a randomly assigned letter, their to provide health care in Aleppo. selected interviewees from contacts profession, and when necessary, the developed through its documentation hospital or organization for which efforts in the region, from attendees they work. of the Syrian American Medical Society’s 15th International Conference The information collected through in Gaziantep from July 23 to July 26, these interviews is supplemented by 2015, and through snowball sampling secondary research conducted by PHR methods.22 through its ongoing work documenting attacks on medical facilities and The PHR team interviewed 13 medical personnel in Syria. doctors (one ear, nose, and throat (ENT) specialist, one emergency medicine PHR’s Ethics Review Board (ERB) doctor, three general surgeons, approved this research. PHR has had two neurosurgery residents, one an ERB since 1996 to ensure protection ophthalmologist, one orthopedist, of human subjects in its research and two pediatricians – one resident, one investigations. PHR’s ERB regulations fully trained – and two urologists), two are based on Title 24 CRF Part 46 pharmacists, one dentist, one forensic provisions (see: http://ohsr.od.nih.gov/ pathologist, two lawyers, and five guidelines/45cfr46.html), which are used by academic Institutional Review Boards (IRBs). All of PHR’s research and investigations involving human subjects must be approved by the ERB and conducted in accordance with the Declaration of Helsinki as revised in 2000.

Physicians for HumanEmbargoed Rights phr.org Draft7 Findings “Within the same period of time, five hospitals were targeted and the targets were very precise. It’s not a coincidence.”23 EmbargoedDr. A, a young pediatric residentDraft working in a trauma hospital in Aleppo

Aleppo’s Health Care Attacks on Hospitals and 13 dead to another nearby hospital. Infrastructure and Personnel PHR documented the first attack on a Two members of the medical team died medical facility in Aleppo on July 30, in the attack.24 Systematic attacks – both targeted 2012, one week after the opposition and indiscriminate – have degraded gained control of the city. Over the As attacks on the city continued, Aleppo’s health care infrastructure next seven months, government forces electricity and phone lines were cut, and decimated the medical workforce. launched 17 attacks on 10 medical leaving radio and walkie-talkies as More than two-thirds of the city’s facilities in Aleppo, the majority with the only means of communication. hospitals are no longer functioning mortar fire, missiles, rockets, and other Medical staff feared the Syrian as a direct result of the conflict, and aerial bombardment (see Figure 1). government could easily intercept this more than 95 percent of the city’s communication, making it easier for doctors have fled, been detained, or The attacks on Dar al-Shifa Hospital, a them to target hospitals, so they created killed. The fact that Aleppo’s health private hospital located in the densely code names for facilities. Hospitals were care system (a skeletal version of populated al-Shaar neighborhood, make labeled M1, M2, etc. (M stands for what existed just five years ago) is evident the deliberate nature of these mashfa, the Arabic word for hospital), able to function at all demonstrates attacks. On August 12, 2012, Syrian and medical points, which often provide the resourcefulness and dedication government forces attacked Dar al-Shifa first aid, were labeled N1, N2, etc. (N of Syrians both inside and outside Hospital with artillery shells fired from stands for nuqta tibiya, the Arabic the country. When their government a helicopter. Two days later, on August term for medical point).25 Physicians destroyed the city’s infrastructure, 14, the hospital was again damaged in recognized that this naming system killed dozens of medical personnel, and an airstrike. The first week in October did not increase protection for long; forced hundreds of their colleagues to saw the hospital’s third, fourth, and the Syrian government would likely flee for their lives, Aleppo’s remaining fifth floors damaged by a series of figure out which hospital was which. health workers did not give up. Feeling rocket strikes. Finally, on November Medical staff discussed changing the a sense of duty toward their neighbors 21, a missile hit the hospital and put it names in 2014 but decided it was not and understanding their departure out of service. Dr. E, a urologist who a high priority.26 would result in further loss of lives and was working at the hospital during the decreased access to health care, they final attack and the other hospital staff March to December 2013 was a period rebuilt a health care system and saved worked from 7 p.m. to 3 a.m. trying to of relative calm in Aleppo. PHR only thousands of lives. But the few health save civilians stuck under the rubble. documented one attack on a medical workers who remain cannot treat many They eventually transported four injured facility there during this time period; of the numerous life-threatening injuries al-Jaban Hospital was destroyed after they confront every day.

Figure 1 Total Number of Attacks on Opposition takes Syrian government Opposition makes Medical Facilities in Aleppo control of eastern starts barrel bomb significant gains in Aleppo campaign nearby Idlib governorate 45 40 35 30 25 20 15 10 5 0 July July July July July May May May May May Jan. Jan. Jan. Jan. Jan. Nov. Nov. Nov. Nov. Mar. Mar. Mar. Mar. 2011 2011 2011 2011 2012 2012 2012 2012 2012 2013 2013 2013 2013 2013 2015 2015 2015 2015 2014 2014 2014 2014 2014 Sept. Sept. Sept. Sept. Sept. Sept. 2012 2013 2015 2014 2011 March

Source: Physicians for Human Rights, “Anatomy of a Crisis: A Map of Attacks on Health Care in Syria.”

8 Aleppo Abandoned: A Case Study on Health Care in Syria Zahri Azrak Hospital, located in the Trab al-Hellok neighborhood in Aleppo city, was attacked on August 25, 2012. The American Association for the Advancement of Science (AAAS) obtained imagery of the hospital that was collected on August 18, 2012 and September 1, 2012, just days before and after the reported attack. The before and after images clearly show damage to the rear entrance of the southern wing of the hospital. The damage observed is consistent with shelling. Photo: Digital Globe Analysis: AAAS

“I call 2014 the barrel bomb era.”27 M10, one of the main trauma hospitals, harm. Many of Aleppo’s physicians and Dr. D was attacked with barrel bombs four residents have fled the city because of times in just 11 days. On June 23, 2014, these attacks. Dr. E estimated that prior sustaining several mortar and aerial Syrian government forces attacked the to the barrel bomb attacks, there were assaults by Syrian government forces. hospital, damaging its emergency room, 10 times as many doctors in Aleppo as operating room, intensive care unit there are today.28 Then, in mid-December 2013, Syrian (ICU), and generators. The following government forces launched an intense day, the hospital was struck again, There was a brief respite from attacks barrel bomb campaign on Aleppo. causing damage to the building, on health facilities from August 2014 PHR documented the first of such oxygen equipment, and generators. through March 2015 in Aleppo. But attacks on a medical facility on January On July 1, government forces again beginning in April 2015, a month 30, 2014. Syrian government forces bombed the hospital, killing four civilians after the Syrian government faced barrel bombed a clinic in Mayasar and injuring seven medical personnel. major setbacks across nearby Idlib neighborhood, killing a doctor and After another attack on July 3 that governorate, attacks increased. member of the Polio Control Task Force wounded seven, the hospital was put From April through July 2015, PHR who were vaccinating children. Since out of service for nearly three months documented 13 aerial attacks on then, Syrian government forces have as staff made repairs and moved the 10 medical facilities, of which 11 were launched an additional 26 airstrikes on facility underground. by barrel bombs and two by rockets medical facilities in Aleppo, 23 of them and missiles. with barrel bombs. Following this series of attacks during the summer of 2014, the health care The underground architecture Between April and July 2014, Syrian system in Aleppo adapted. Where undoubtedly increases medical government forces perpetrated at least possible, workers moved facilities facilities’ protection, but “that is still 13 attacks on seven medical facilities underground to protect them from not enough,” said Dr. D, a urologist in Aleppo. Of these attacks, 12 were future attacks. In other cases, they who works at M10.29 On April 28, with barrel bombs and one was with a stopped working on the top floors of Syrian government forces again barrel rocket. Multiple medical facilities were their buildings, which are the most bombed his hospital, the same facility attacked repeatedly, forcing them to likely to be destroyed in an airstrike. In that moved underground in July 2014 reduce service or close completely. addition to the threat of death, barrel following four devastating attacks. bombs cause enormous psychological Dr. L, a neurosurgery resident at M10,

Physicians for HumanEmbargoed Rights phr.org Draft9 Findings continuedEmbargoed Draft

One Doctor’s Courage was there during the April attack. alarm sound, you have maximum two “In the first few moments, I couldn’t minutes” before a barrel bomb will fall, Dr. L is one of the few physicians concentrate on anything. I only heard Dr. L explained. But there are no alarms who chooses to live with his wife the sound of the barrel falling. It’s a for warplanes.33 Hackers also intercept and young son in Aleppo rather very high sound and horrible, actually. radio communication from the Syrian than commute from Turkey. He It makes you fear; a very big amount of government. In a few cases, hackers described their lifestyle in the fear you see in the faces of others.”30 have overheard reports of impending city: “Our house is normal. It has The attack damaged generators, attacks on hospitals, physicians said, rooms, a garden, a fountain... We the outpatient clinic, and medical and hospitals have been alerted via have trees and flowers. It’s not as equipment including an ICU monitor walkie-talkies.34 bad as we imagine. But the fear and oxygen cylinders. The following when the airplanes come, it’s the day, Syrian government forces again Ideally, hospitals should be evacuated most important fear. We have no barrel bombed the hospital, causing when there is warning of an attack, way to manage that.” There have additional damage. The hospital was but in practice, that is very difficult. been numerous attacks near his out of service for 20 days as staff There is often no time and no place to house but no direct hits yet. He made repairs and reinforced the transfer patients, and closing a hospital said about the most recent attack, building. They surrounded it with bags would limit access to health care for “We woke up with a bvvvvvv,” and barrels filled with sand, trying to those injured in the impending attacks. imitating the sound of a warplane. protect themselves from the shrapnel- Even when hospital directors have “We had no time to escape or filled barrels they are certain will fall recommended that staff evacuate a hide under the bed or behind again. Dr. D said, “The old building is hospital, many have chosen to remain the door. It was a very terrible close to being destroyed. Maybe in the and risk their own lives in order to and horrible experience.” When next strike, I don’t know.”31 save others.35 asked how he takes care of himself psychologically, he responded, “Like To date, the Syrian government has Hospitals in Aleppo have also adopted the others, we try to be normal. We been the only perpetrator of attacks on techniques that cars were using early try to adapt to the situation and medical facilities in eastern Aleppo city. on in the conflict – turning off lights protect ourselves, so we live our However, some physicians noted that at night. Dr. R, a general surgeon who lives as normal and forget we are in opposition groups have interfered with recently stopped working at a trauma danger. When we are attacked, we medical work in the city. Dr. L explained hospital in Aleppo, explained that cars laugh and sing, ‘We will stay here, that armed groups have come into cannot use lights at night because, “it’s we will stay here.’” hospitals with weapons and demanded a sign for the plane to bomb.” Hospitals that their patient receive treatment started adopting the practice as well. immediately. “We always manage “Sometimes we turn off the lights in this by calming the atmosphere and the hospital if we feel that there may be explaining the injury and what some attack coming. Sometimes light is the treatment is.”32 Such coercion a problem.”36 is a violation of medical neutrality, the principle under IHL that health Despite developing and adopting care is protected and must be survival techniques, hospitals in Aleppo provided impartially. continue to be attacked, severely damaged, and destroyed. Most Survival Techniques hospitals still functioning today have Over the past three years, Aleppo’s been attacked repeatedly, M10 up residents have learned how to mitigate to seven times. With such frequent the impact of aerial attacks. The attacks, physicians in Aleppo have no city now has a warning system to doubt that the government is targeting alert people of an impending attack. their hospitals. When a helicopter is spotted, people will notify the system, which then blasts an alarm. “When you hear the

10 Aleppo Abandoned: A Case Study on Health Care in Syria “Maybe we are only a few physicians in a simple hospital and with simple equipment, but we save a lot of lives.”37 Dr. D

Organizing bodies, funders, and medical staff sometimes have different definitions of facility types. PHR defines the different medical facilities as follows.38

Figure 2 Definitions of Types of Medical Facilities

Field Hospital39 A medical facility equipped to provide surgery or other inpatient services Medical point and first aid point A medical facility staffed with medics and volunteers, equipped to provide first aid, stabilize patients, and refer cases to nearby hospitals; are often closer to frontlines than hospitals and serving as the first point of contact for patients Clinic and medical center A medical facility equipped to provide outpatient services; often specializing in specific treatments, such as pediatrics, dental, and obstetrics and gynecology Polyclinic A group of clinics with multiple specializations Mobile clinic A small clinic run out of a vehicle such as an ambulance or a van Ambulance network A medical facility with ambulances equipped to provide first aid, triage patients, and refer patients to hospitals; patients can come to this facility for treatment, or teams from this facility can provide first aid in the field Blood bank A medical facility that stores blood and products for transfusions Dispensary A medical facility equipped to provide medication and vaccines

Medical Infrastructure What is clear from interviews is Most, if not all, of Aleppo’s field that Exists Today that there is a significant lack of hospitals are located in buildings that As of August 2015, there were 10 sophisticated medical equipment in served as medical facilities before the hospitals40 functioning in Aleppo – Aleppo. At the time of writing, there conflict. While this puts the facilities at just 30 percent of the 33 functioning were only three dialysis clinics, and greater risk of attack because the Syrian hospitals in 2010,41 which included some one was out of service.44 There were government knows their locations, of the city’s largest with specialized also no functioning computerized this is a risk the medical community in services.42 Today’s functioning hospitals tomography (CT) or magnetic resonance Aleppo is forced to take. It is very costly include seven field hospitals for trauma imaging (MRI) machines for over a to outfit a non-medical building with surgery, an ophthalmology hospital, year, and there is still no MRI machine specialized wiring for oxygen, water, an obstetrics and gynecology hospital, at the time of writing.45 A CT scanner and electricity, among other things, and and a specialized children’s hospital. was delivered to one of the large funding organizations cannot afford Hospitals range in size and capacity, trauma hospitals in August 2015, but to effectively build new hospitals.48 Dr. with some facilities having as few as two it broke after two weeks of use and K, a dentist working in Aleppo, also or four doctors and another having as was undergoing repairs at the time of recognized that relocating medical many as 13.43 The equipment available writing.46 Maintaining a CT scanner facilities to different buildings would in each hospital also varies widely; some (or any other specialized equipment) in only increase protection for a short time. hospitals have no ICU beds while others Aleppo is extremely costly and resource “A single massacre is enough to expose may have several. prohibitive, requiring specialized tools the [hospital’s] location,” as the Syrian and a trained technician for constant government could just track the flow repairs.47 Even when the equipment is of injured patients to the hospital’s available, it is often substandard. For new location.49 example, an ICU bed could be anything from a bed equipped with respirators In addition to field hospitals, Aleppo and cardiac monitors to simply a bed has a number of clinics and centers for with an IV attached. specialized services, medical points to

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provide first aid and perform triage for Council, Free Medical Association, Medical Personnel trauma patients, and other medical and Union of Free Syrian Doctors are Who Remain Today facilities to provide specialized care. three of the main coordinating bodies Many of the clinics are in geographically that help to run health facilities in Physicians in Aleppo fixed locations, but medical points Aleppo, in addition to the Aleppo PHR estimates that there are a can change locations based on needs Health Directorate. The supporting and maximum of 70 to 80 physicians50 and the security situation, as they funding organizations – which include who work in Aleppo over the course require less specialized equipment. PHR (among others) the Syrian American of one month. However, as most estimates that there are 20 clinics and Medical Society, Union Internationale physicians only work 15 to 20 days medical centers, three dental clinics (the des Organisations de Secours et Soins each month (and spend the rest of their only source of dental care), four medical Médicaux, Médecins Sans Frontières, time in Turkey with their families), the points, and a blood bank in Aleppo. and Medical Relief for Syria – provide total number of physicians working While these facilities are numerous, facilities with money, medical supplies, at one time is only 50 to 66 percent they, like all facilities in Aleppo, are likely and equipment and also help run them. of the total number. Thus, at any under-equipped and understaffed. This lack of organization among the given time, it is estimated that there numerous coordinating bodies and are only 37 to 50 physicians working. Aleppo does not have a centralized funding organizations is inefficient and Put into perspective, approximately 5 health care system with one has likely led to both overlaps and gaps percent of Aleppo’s pre-war physician organization coordinating operations, in coverage, communication, and aid population remains today.51, 52 Although services, and personnel throughout deliveries throughout the city. the city’s population has decreased to the city. The Aleppo City Medical approximately 300,000 residents, nearly a quarter of what it was in 2010, there is now approximately one doctor for every 7,000 residents compared to one doctor for every 800 residents in 2010, as illustrated by Figure 3.53

Figure 3 One Doctor for Every 7,000 People in Eastern Aleppo City

In 2010 there were approximately In 2015 there are approximately 800 people for every doctor. 7,000 people for every doctor.

= 200

12 Aleppo Abandoned: A Case Study on Health Care in Syria “I lost many of my faithful friends as they worked to save others’ souls.”54 Dr. D

Figure 4 Breakdown of Physicians’ Specialties in Aleppo, July 2015

Specialty Total General 22–25 Internal medicine and 15–18 general practitioners Emergency medicine 7

Surgeons 26–27 General surgeons 7–8 Orthopedic surgeons 7 Vascular surgeons 2 Thoracic surgeons 1 Urologists 5 Elise Baker, PHR program associate interviews a doctor from Aleppo whose Plastic surgeons 1 identity has been obscured for security purposes. Renal surgeons 1 Figure 4 provides a breakdown of Dr. K told PHR there is only one Neurosurgeons 2 the number of physicians in Aleppo female obstetrician/ gynecologist according to their specialty.55, 56 The that he knows of working in the Other Specialists 22–25 best-represented specialties in Aleppo city, and she has stayed throughout are internal medicine, general practice, the conflict because, “she knows Neurologists 1 emergency medicine, general surgery, women will die if she leaves.”57 Dr. Cardiologists 1 orthopedic surgery, and pediatrics. H, a general surgeon working with There are three or four of each of an organization that documents Ear, Nose and Throat (ENT) doctors 4 these specialists working in the city at health issues in Aleppo, thought Pediatricians 9–10 any given time, along with one or two there might be two or three other urologists, ENTs, and gynecologists. female physicians at most. As Syria Obstetricians/Gynecologists 4-5 However, with only one thoracic had relatively equal numbers of Ophthalmologists 2 surgeon, plastic surgeon, renal surgeon, male and female physicians before neurologist, and cardiologist, there the conflict, this gender ratio is Anesthesiologists 1-2 are guaranteed gaps in coverage for indicative of the large number of these specialties. female physicians who have fled Total 70-77 the country.58

Another Colleague Lost

On July 25, 2015, the only urologist government forces. Many of the in hospital – we won’t find working in a hospital in northern physicians PHR interviewed the next another surgeon to work there. We was killed day had been friends with him. Dr. D need help to protect our people. when the car in which he was said in his interview, “Our colleague Every physician, doctor, nurse killed, traveling was bombed by Syrian who was killed yesterday worked we haven’t another.”

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Conditions for Physicians to you. You need to care for yourself to Still, these doctors and other health Aleppo’s health professionals have keep going.”61 When asked about the workers stay, knowing that if they learned to provide care in a dangerous psychological trauma they face every leave, nobody will replace them. Dr. L, and low-resource setting. They live in day in Aleppo, some physicians were the neurosurgical resident, said: “Our constant fear of the next attack and able to discuss their mental health while people need us. When every man leaves with the grim reality that none of the others were not. After describing a his country and goes outside, who will protections for medical facilities and barrel bomb attack on his hospital, stay in the city and give the services to personnel, mandated by international Dr. A, the pediatric resident working in a the people?”65 Dr. B, one of the few law, are enforced for them. trauma hospital in Aleppo, said, “Don’t ophthalmologists in the city, echoed even ask me about the shock.”62 It was this sentiment: “It’s obvious we’re not Because there are so few of them, clear that all physicians have struggled going to leave. This is our duty. We’re physicians working in Aleppo explained with and continue to struggle with the not getting any new doctors. If I leave, that they don’t have shifts at their trauma inherent in providing health care there will be too big of a gap. If they get hospitals. When they are in Aleppo, in a war zone. a patient with a foreign object in his eye, physicians remain in medical facilities where will he go?”66 almost 24/7, working, eating, and The physicians PHR interviewed sleeping there in order to respond acknowledged that they could leave Other Medical Personnel immediately when there is an attack. at any time and find work in Turkey or PHR estimates that there are Dr. A said he’s been unable to take days Europe, as many of their colleagues have approximately 180-190 nurses working off in the city because the need is so done. The low and often infrequent in field hospitals, in addition to the great. In order to take a break, he leaves salaries are certainly not an incentive to many more working in clinics, medical and travels to Turkey.59 stay. While a number of organizations points, and other medical facilities provide support for surgical equipment around the city. Prior to the start of the Several physicians noted the high rate and medication, fewer groups conflict, there were nearly three doctors of burnout among their colleagues. provide money for salaries, hospital for every two nurses.67 Now, there are Said Dr. S, a general surgeon working maintenance, and repairs. “We find it more than two nurses for every doctor. in Aleppo: “In Arabic there is a phrase, shameful and insulting that we have This shift is likely due to the exodus of ‘There are some working fuses still in to worry about finances when we are so many physicians, who often have your head.’ If all your fuses are out, you risking our lives and saving lives, and more financial means and a greater can’t take any more. There are many there are no salaries for people,” said ability to find work outside Syria than colleagues who worked so hard and Dr. K. “Donors will not provide money other health professionals. In addition, then had to leave and stop because they for running costs and salaries.”63 With a nursing school was established in got so depressed and couldn’t sleep. insufficient and sporadic funding, Aleppo after the start of the conflict.68 This moment can happen at any time – hospitals are left with low quality and This initiative is yet another example of you can’t know when it might happen sometimes ineffective medication and Syrian health workers’ ingenuity and equipment, lack of oil for generators, resolve. It has increased the number of little material to reinforce hospitals after staff and thus access to health care in “My family respects my choice to live attacks, and inadequate salaries for Aleppo, but it suffers from the same and work in Aleppo, but they live in nurses, medics, and other lesser-paid lack of resources that the hospitals do.69 fear. It is not an easy thing.”60 medical personnel who struggle to work Dr. K in Aleppo and support their families.64

A Commitment to His People

Dr. A was completing his pediatric as an individual, especially when the with myself. It’s our country and if we residency when the conflict broke person has the potential to continue leave, it will fall apart. I think maybe out. Despite his family’s wishes, he elsewhere. That’s the opinion of I will leave and specialize and come has remained working in Aleppo. 95 percent of mothers and fathers back with better skills. But then I “It’s natural for a family to be in Syria.” When asked what keeps see how much the people need me. against the decision because they him in the city, he laughed. “It’s a Maybe that’s the biggest thing that’s care about their child’s development difficult question that I’m dealing keeping me inside.”

14 Aleppo Abandoned: A Case Study on Health Care in Syria “There are weapons we didn’t imagine and injuries we didn’t see in the books.”70 Dr. L

Provision of Health Care city, which was part of daily life for A Mother and Her Daughter for Traumatic Injuries those with homes, family, and work on either side of the city. Snipers would Dr. D recounted the story of a Despite greatly diminished staff, position themselves on towers and in barrel bomb attack in a residential equipment, and facilities, health workers buildings and target people – mostly area. “There was one case where have found ways to provide treatment, civilians – as they crossed.74 This practice a mother’s and daughter’s home ensuring that Aleppo is still a somewhat became a game for the snipers, and was struck by a barrel bomb. The livable city. But the abundance of physicians started noticing patterns each daughter caught the mother’s hand, severe trauma injuries, especially from day – shots only in the groin one day, and that was all that was left of barrel bombs, is stressing the available in the neck the next day, the stomach them. The rest of their bodies were emergency care far beyond its capacity of pregnant women the next.75 As the not found. I saw that.” Following his and resulting in countless civilian deaths. urologist Dr. D explained, “Sometimes interview, the doctor e-mailed PHR snipers attacked children or pregnant a photo of the two hands clasped Injuries Seen ladies. But that does not happen together. The mother is wearing a Medical personnel in Aleppo have anymore because the death corridor gold watch on her wrist, and her seen a range of injuries, from textbook is closed.”76 child’s hand is half the size of hers. broken bones and lacerations to Midway down their forearms, their previously unimaginable wounds. After the Syrian government started flesh is shredded. Doctors and first The most common injuries are on the using barrel bombs in late 2013 and responders never found the rest of abdomen, chest, and limbs.71 Dr. H, a reduced its use of mortar fire, rockets, their bodies. general surgeon, explained, “It’s human and missiles, the number of injuries instinct to hold your hands up and resulting from a single attack – and their protect yourself, so that’s where the severity – increased.77 Barrel bombs injuries are.”72 obliterate anything and anyone they hit directly and inflict head to toe injuries While the types of injuries have largely on anyone in their large blast radius.78 remained the same, the weapons used Dr. E, the urologist from Dar al-Shifa and extent of injuries have changed over Hospital who moved to a field hospital time. Physicians in Aleppo described after his original hospital was destroyed, seeing typical injuries from bullets, estimated that barrel bombs cause knives, mortar fire, and rockets early on three times as many injuries on a single in the fighting. These weapons would patient as rockets and missiles cause.79 most often cause a single injury on an These patients with multiple injuries individual – a broken bone, laceration, are sometimes impossible to treat, as or rarely, a severed limb.73 there is rarely enough time for multiple specialized surgeons to dedicate There were also many injuries from themselves to a single patient in need of sniper attacks. After fighting split the numerous operations.80 Dr. S described city in half, with opposition forces the horrific nature of these weapons controlling the east and government and their resultant injuries: “I felt well- forces controlling the west, there was a trained, but nobody could be prepared single crossing between the two sides for the complexity of the wounds we named the “corridor of death.” This see. None of us felt prepared. We just two-block street was the only way to do the best we can.”81 The extent of travel between the two sides of the these injuries illustrates why the use of indiscriminate weapons in civilian areas constitutes a war crime.

Physicians for HumanEmbargoed Rights phr.org Draft15 Findings “We joke that our complications range between paralysis continuedEmbargoed Draftand death. It’s very bad.”82 Dr. L

Treating Traumatic Injuries medicine doctor and a surgery assistant Due to a large number of patients at the largest trauma hospital in Aleppo. Syrians carry a wounded man on a with life-threatening traumatic injuries He also provides pediatric services in stretcher following a reported barrel requiring surgery, doctors working in specialized clinics in his spare time.85 bomb attack by government forces Aleppo do far more than their medical on the opposition-held area of school and residency training prepared These doctors learned to perform al-Maadi in Aleppo. them for. They frequently are forced to surgeries outside of their expertise by Photo: Karam al-Masri/AFP/ act as general surgeons or emergency observing other surgeons in Aleppo Getty Images medicine physicians, even though many and at hospitals along the Syrian- were not formally trained in these Turkish border, attending lectures and fields. Dr. L, who was in the middle of trainings in Turkey, and then assisting his residency in neurosurgery when the in surgeries.86 Physicians also learned conflict broke out, most often assists new skills and operations from foreign in general surgery and rarely performs doctors – mainly trauma surgeons – any neurosurgery because there are who came to work in Aleppo early on seldom any functioning CT scanners in the conflict. Dr. N, an emergency in Aleppo.83 Dr. D, the urologist who medicine doctor working in a trauma works as the director of one of the hospital in Aleppo, explained that largest trauma hospitals in Aleppo, thoracic and cardiovascular injuries went performs not only urology surgery but untreated until a British cardiologist also trauma surgery.84 Dr. A, who was in visited a year and a half ago and trained his pediatric residency when the conflict doctors.87 Later, physicians on staff were broke out, works as an emergency able to successfully repair a patient’s

16 Aleppo Abandoned: A Case Study on Health Care in Syria left ventricle, even without a thoracic Services Not Provided “If you see brain matter coming out specialist at the hospital.88 These visiting Although medical staff have been or crushed limbs, you know you physicians greatly improved health care remarkably successful at providing can’t treat them.”101 in the city. But, says Dr. D, “Foreign services outside their expertise and Dr. H doctors don’t come anymore. This is a making do with the limited equipment big problem because there are only a and supplies they have, many injuries few surgeons [left].”89 are beyond treatment in Aleppo. In treatment impossible. There are no some cases, a hospital might have pathologists to diagnose cancers and Physicians have also had to learn to the appropriate specialist but not the provide pre-op and post-op services, no perform new operations on the spot. necessary equipment, as is the case with nephrologists to treat renal failure, and Dr. K, a dentist who was never trained neurological injuries. Although there no dermatologists to provide specialized in maxillofacial surgery,90 was the only are two neurosurgeons in the city (Dr. services (although dermatological doctor available one day to operate on L and an Egyptian neurosurgeon who medicine is available).102 Endocrinologists a patient whose jaw was completely works part-time), neurosurgery has are also unavailable. According to destroyed by a sniper shot. “I had to do been impossible without a functioning Dr. R, “Four months ago, a doctor deep sutures of the muscle, which was CT scanner. Spinal injuries, too, are entered [Aleppo] to work with us and my first time, so I learned by doing that. nearly impossible to treat without a CT was killed one week later on the road. I closed the patient and hoped that I or MRI machine.96 Ophthalmologist He was the only endocrinologist.”103 had done a good job.”91 Dr. B can provide emergency care and remove foreign objects and blood clots Even when initial operations and After an attack, patients are most often from eyes, but he can’t perform most treatment are possible, follow-up care sent to the closest hospital in the city, eye surgeries since the ophthalmology may not be. With post-operative care as all of Aleppo’s hospitals are able to hospital in which he works does not often unavailable, serious infections provide emergency care. If the hospital have the specialized microscopes after surgeries, often resulting in is overcrowded, or if the patients required for such procedures.97 The amputations, are common. Severe burns need specialized services, they’re lack of well-equipped ICU beds also are also difficult to treat, as patients likely transferred to other hospitals limits the number of intensive and require intensive follow-up care in in ambulances, which are also invasive surgeries that can be performed specialized facilities. And rehabilitation frequently attacked.92 at one time.98 services are non-existent. “When a patient doesn’t die from these injuries, A large influx of patients after an attack In addition to equipment, the lack he will have a difficult life without presents even greater challenges, as of specialized staff limits the type of limbs, or [his] sphincter muscles will stop a doctor must quickly determine who surgeries that can be performed. As working,” said Dr. R, a general surgeon. might survive with immediate treatment, there are very few vascular surgeons, “Sometimes they become paraplegic who could wait for treatment, and thoracic surgeons, and cardiologists, or quadriplegic. These patients survive, which cases are hopeless.93 “When a most of those cases cannot be treated but they need constant care and massacre happens, you have hundreds adequately inside Aleppo.99 Dr. A can’t get better. Psychologically, they of people being rushed to the hospital said he has seen many patients with are hurt. It’s becoming a social or with horns honking outside, relatives treatable vascular injuries hemorrhage community problem. Rarely do you see screaming, and everything covered in to death.100 Other specialties are organizations adopting and addressing dust,” Dr. S explained. “Everyone wants completely absent from the city, making these issues... Wheelchairs and walkers their patient to be the first treated. exist, but nothing beyond that.”104 We leave them on the floor and try to start the triage. It is very complicated to figure out who should go first.”94 The staff try to treat everyone, but as Dr. D added, “If the prognosis is not good, we do not operate.”95

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Referrals to Hospitals in Turkey While no physician interviewed conflict began, they are seeing increases When asked how they deal with knew how many patients referred to in rates of pre-existing illnesses. This patients who require services not Turkey survived – they do not have rise, they explained, is largely due to the available in Aleppo, every physician the capacity to follow up with and breakdown of the health care system. PHR interviewed said that patients monitor patients referred elsewhere The most commonly seen illnesses are referred to hospitals in Turkey. – one physician estimated that 10 include acute diarrhea, influenza, When questioned further, it became percent of patients referred to Turkey dermatological diseases (scabies, lice, obvious that the referral system is not a with neurological injuries survive, and leishmaniosis, and fungal infections workable solution, and some patients perhaps 60 to on the scalp and skin), respiratory refuse to be transferred.105 Patients must 70 percent of patients with other illnesses, and Hepatitis B.115 The rates be driven to Turkey in ambulances (as injuries survive.109 for these illnesses also tend to fluctuate they require stabilizing medical services), depending on the season; diarrhea which are in short supply in Aleppo, Because the referral system is increases in the summer, and respiratory and the drive is extremely dangerous.106 imperfect, especially for patients illnesses increase in the winter.116 Rates There is only one road in and out of needing immediate intensive care, of water-borne diseases have also Aleppo: Castello road. It is about 20 many patients die simply from a lack risen significantly, as access to clean meters wide, sandwiched between of medical care inside Aleppo.110 Dr. water is limited, and chlorination Syrian government- and IS-controlled A explained that neurological injuries tablets for purification are not readily territories, and frequently bombed by result in the highest proportion of available.117 Rates of malnutrition and government forces. According to Dr. F, a deaths compared to any other injury.111 resulting dwarfism are rising, especially physician working with an organization But multiple trauma wounds on one in children.118 in Turkey that supports health care in patient (common in barrel bomb Aleppo, “If a jet is in the sky, nobody attacks) cause the largest total number Services Provided will go in or out [of the city].”107 It is also of deaths.112 Dr. N stated, “Sometimes As the ability to treat traumatic injuries unsafe to drive at night, as government when there are multiple injuries, has decreased, so too has the ability to forces will bomb cars they see traveling especially abdominal injuries, the odds treat chronic illnesses.119 Provision of care with their lights on. are against survival.”113 depends upon the available personnel, equipment, and medicine. While If transportation is possible and patients Provision of Health Care for services and medication are available for survive the few-hours drive to the Chronic and Acute Illnesses many chronic illnesses, the quality and Turkish border, the patients may face adequacy of supply are often severely difficulties crossing into Turkey. When Shortages of personnel, equipment, lacking. “There is no such thing as border crossings are closed to the medicine, and necessities such as clean enough,” Dr. A said. Doctors and nurses general public, Turkish authorities will water and electricity have caused a often can only give patients medication still allow emergency medical cases and breakdown in Aleppo’s health care for a few days.120 50 “cold cases” (non-emergency cases) system, resulting in an increase in to enter the country each day. However chronic and acute illnesses. Provision Small amounts of medication are on these days, Dr. F said that Syrians of care for these illnesses ranges from available for patients with heart disease, without medical conditions (who are inadequate to nonexistent, and, as diabetes, and asthma.121 Only the most not allowed to cross into Turkey when a result, patients are dying from basic forms of hypertension medication the borders are closed) sometimes cross treatable conditions. are available for patients with renal as some of the 50 daily cold cases. The failure.122 Some antibiotics, such as lucky few who arrive in Turkey then face Illnesses Seen vancomycin, are available, but not in additional complications – language Hospitals are inundated with patients large enough quantities.123 The Free barriers, long wait times, and unclear requiring emergency care for conflict- Medical Association recently held a legal status.108 related traumatic injuries, so most campaign to treat scabies and lice, but patients with chronic and acute they did not have sufficient medicine illnesses receive medical care in clinics, and had to place an emergency request where some doctors volunteer.114 While for more.124 doctors report they have not seen any new illnesses in Aleppo since the

18 Aleppo Abandoned: A Case Study on Health Care in Syria Storage presents another limitation. Services Not Provided Many medications need to be A large number of services and A Syrian boy suffering from the ‘Aleppo refrigerated, but frequent electricity medications are unavailable for button’ (a welt caused by leishmaniasis) outages from fighting make maintaining chronic illnesses. Aleppo lacks newer stands with family members at a cool temperatures nearly impossible. generations of cardiac and asthma clinic. The latest affliction to hit Large quantities of medications such as medicines and antibiotics.128 While weary residents of Aleppo is written insulin and vaccines have been ruined there is now a center to provide blood on their faces. from substandard storage. This has led transfusions, which is essential for the Photo: Bulent Kilic/AFP/Getty Images to increases in preventable contagious treatment of certain blood diseases such diseases, as was the case with polio in as thalassemia, the city largely lacks There are also profound unmet mental southwestern Deir ez Zor governorate the vaccines and medication necessary health needs in Aleppo, as there are no in 2013.125 to accompany the transfusions.129 psychiatrists or psychologists.132 With Aleppo is also severely lacking in the amount of death and destruction A lack of clean water further diagnostic services for liver disease, Aleppo’s residents and health workers complicates some treatments. Aleppo’s which is increasing in prevalence from have witnessed, there is great need two functioning dialysis clinics (staffed breakdowns in the health care system. for psychological services. However, by technicians rather than physicians, as Its symptoms are similar to other none of those interviewed knew of there are no nephrologists remaining illnesses, so it is difficult to diagnose, organizations or individuals assessing in Aleppo) are equipped with the said Dr. C, a pathologist. “It’s a silent needs or providing these services in necessary machines and medication. disease and a slow execution.”130 Kidney the city. Dr. N said that services were But the machines require purified water, failure is increasing in diabetics due provided to staff at his hospital after which is not easily accessible.126 Access to limited quantities of medication, they treated victims of a massacre at to clean water in Aleppo has ranged improper storage, and lack of follow-up a nearby school, but the services were from spotty to nonexistent since early care.131 And, in general, a lack of services only available temporarily.133 2013 due to frequent electricity cuts, is leading to the spread of treatable and damage to the water system from preventable illnesses. Few, if any, organizations are collecting bombing, decreasing sanitation and comprehensive data on chronic and hygiene, and a lack of access to and acute illnesses. However, physicians told availability of purification methods.127 PHR that the lack of available services for these illnesses is a predominant cause of death in Aleppo. Physicians for HumanEmbargoed Rights phr.org Draft19 ConclusionEmbargoed Draft

“The whole world can see, but When asked whether he wanted his Syrian health workers have spent the they don’t want to do anything. children to become doctors, Dr. E, a past four years desperately urging the The barrels aren’t precise. urologist, responded, “No. Anything international community to enforce laws They’re killing civilians. Nobody except doctors. Maybe engineers and protect them. The international in the history of the world has or lawyers.”135 With the Syrian community has heard these cries and struck their civilians with this government’s unprecedented assault yet continues to watch hundreds of vicious, barbaric weapon. on health care, it is no surprise that he health workers die and hard-won norms Forget political ideologies does not want his children to follow erode while offering only conciliatory and religious beliefs, these in his footsteps in choosing a life- food baskets and polio vaccinations. The barrels are killing civilians.”134 threatening career. UN Security Council has utterly failed Dr. B in its mission to maintain peace and The consequences of these repeated security. It has succumbed to politics, attacks, which amount to crimes against and millions of Syrian civilians are humanity, are rippling throughout the suffering as a result. While it continues country. Civilians are being targeted to sit on its hands, the international with devastating weapons, creating community is complicit in each an enormous need for emergency additional civilian death. medical care. However, these services, along with routine medical care, The limited lifesaving action the UN are often unavailable as the health Security Council has taken on Syria care system has itself been ravaged. was to pass Resolutions 2139 and 2165 Syria’s humanitarian crisis, the worst more than a year ago. Resolution 2139 in this generation, was created and is expressly called for an end to attacks maintained by the Syrian government. on civilians and civilian objects, use With limited access to lifesaving of indiscriminate weapons (including medication, treatment, vaccines, health barrel bombs), and attacks on health care providers, and safe spaces to facilities and medical professionals. access health care, Syrians are dying of Resolution 2165 called for direct treatable wounds and illnesses. delivery of humanitarian aid – including medical supplies and equipment – to Aleppo’s medical community agrees opposition-controlled areas, where the that the only way to improve health Syrian government was refusing to send care and begin to restore the system is lifesaving aid. Despite these resolutions, to address security. “If it weren’t for the the Syrian government continues to shelling and bombing, we’d have five bomb hospitals, kill health workers, and to six times more doctors in Aleppo,” block critical humanitarian aid deliveries said Dr. R.136 PHR heard the same refrain to opposition-controlled areas. With the from every person interviewed. “If the Syrian government’s well-documented barrels stop, doctors will come back. We non-compliance, the UN Security just need to stop the barrels; it’s the first Council must take additional measures and the last thing we need,”137 said Dr. to enforce Resolutions 2139 and 2165. E. Dr. N agreed, “Stop the barrel bombs. That is the only thing the world can help When asked why he stayed working us with.”138 in Aleppo, Dr. N responded: “I lost a brother in Aleppo, and I can’t give up on a city where my brother gave up his life.”139 The international community cannot give up on Syria and its people’s demand for human rights and dignity, which has cost hundreds of thousands of lives.

20 Aleppo Abandoned: A Case Study on Health Care in Syria Epilogue

The situation in and around Aleppo has changed considerably since late July, when PHR conducted research for this report. In early September, after four years of supporting the Syrian government with weapons shipments and financial backing, the Russian government began a significant military buildup inside Syria, expanding existing air bases, sending combat aircraft and weapons, and deploying troops.140 On September 30, Russian forces launched airstrikes in Syria allegedly against IS, marking the country’s first direct engagement in hostilities.141 These airstrikes were coupled with ground offensives by Syrian government forces and their allies across central, western, and northern Syria.142 Children in front of tents housing displaced Syrians in a camp on the outskirts of Aleppo. Tens of thousands of Syrians have fled their homes The Russian Ministry of Defense in Aleppo since a government offensive there began on October 17, 2015 announced that as of November 3 backed by Russian airstrikes. its aircraft had carried out a total of Photo: Fadi al-Halabi/AFP/Getty Images 1,631 combat sorties targeting IS and terrorist locations.143 Analysis by The have resulted in the displacement of an The pain, suffering, and death stalking Carter Center, however, illustrates additional 100,000 Syrians from Aleppo Syrians is a direct result of the UN that 85 percent of Russian airstrikes governorate’s southern countryside.146 Security Council’s repeated failure to targeted areas controlled by opposition The increased displacement, attacks, overcome powerful states’ self-interest groups, rather than by IS.144 The Russian and closure of medical facilities nearby and stop attacks on civilians and medical government appears to be following have certainly increased pressure on spaces. Millions of Syrians are paying President Assad’s lead in labeling all Aleppo city’s already overwhelmed the price of a morally bankrupt system opposition groups as terrorists and health care system. of international governance. They, attacking them and their civilian who have been utterly abandoned, are supporters. The Russian military has As this report indicates, the greatest asking the international community also followed in the Syrian military’s threat to health care in Syria is continued and UN Security Council for protection footsteps by attacking the health care aerial bombardment. The past month from their government and now system, an explicit violation of IHL. of airstrikes illustrates that Russia’s Russia – a permanent member of the Through the end of October, PHR has involvement in the conflict has increased Security Council that first protected the documented 10 attacks on medical this threat and significantly degraded an murderous Syrian government with its facilities by Russian airstrikes in Syria.145 already dire situation. The UN Security veto power and is now compounding While PHR has not documented any Council, as the body charged with violations. If the UN Security Council Russian airstrikes on medical facilities maintaining international peace and and international community have any inside Aleppo city through October security, must promptly take action to hope of regaining credibility in the 31, PHR has documented five attacks save lives by ensuring the Syrian and future and preventing these violations on facilities in the city’s suburbs and Russian governments cease all attacks from becoming the new normal in southern countryside. Four of these on medical facilities and civilian spaces, armed conflicts around the world, they medical facilities were forced to close as required by IHL and Security Council must heed Syrians’ calls by immediately following the attacks. These airstrikes Resolution 2139. and decisively taking action to save lives. were launched alongside a ground They must prioritize civilian protection offensive by the Syrian government and and human rights over power politics.

Physicians for HumanEmbargoed Rights phr.org Draft21 RecommendationsEmbargoed Draft

To the UN Security Council: To all parties to the conflict: To the international community: Immediately publish and implement Immediately stop all attacks that violate Given the failure of the UN Security additional measures to address the the Geneva Conventions and other Council to refer the situation in Syria Syrian and Russian governments’ international humanitarian laws. to the International Criminal Court, non-compliance with Resolution 2139 support other credible justice initiatives in a manner that will, at a minimum, To donor governments: to ensure that perpetrators of war end attacks on civilians, health Increase funding for humanitarian crimes and crimes against humanity professionals, and medical facilities, assistance so that the UN Office for the are held accountable. These initiatives and ensure the full implementation Coordination of Humanitarian Affairs could include the creation of an ad-hoc of Resolution 2165. and other humanitarian organizations or special court and the prosecution can increase direct cross-border aid of appropriate cases under universal To the Syrian and to ensure that medical facilities in jurisdiction. Russian governments: opposition-held areas have adequate Immediately cease and desist equipment and supplies to address the attacks on medical facilities, health acute and long-term health needs of professionals, and other elements the people living in these areas. Also of the health care system. increase funding for salaries and other operational costs to ensure that health professionals are able to remain working in Syria.

A Syrian man mourns his father following a reported barrel bomb attack by government forces in the al-Muasalat area of Aleppo. Photo: Tamer al-Halabi/AFP/ Getty Images

22 Aleppo Abandoned: A Case Study on Health Care in Syria Endnotes

1. Interview with Dr. D, Gaziantep, Turkey, 14. Caerus, “Mapping the conflict in Aleppo, 25. Interview with Dr. K, Gaziantep, Turkey, July 26, 2015. Syria,” February 2014, http://caerusassociates. July 26, 2015. 2. Interview with Dr. M, Gaziantep, Turkey, com/wp-content/uploads/2014/02/Caerus_ 26. Interview with Dr. A, Gaziantep, Turkey, July 28, 2015. AleppoMappingProject_FinalReport_02-18-14.pdf; July 26, 2015. 3. Physicians for Human Rights, “Anatomy of a Crisis: Interview with Dr. M, Gaziantep, Turkey, 27. Interview with Dr. D, Gaziantep, Turkey, A Map of Attacks on Health Care in Syria,” accessed July 28, 2015. July 26, 2015. November 18, 2015, http://www.phr.org/syria-map. 15. MacFarquhar, Neil, “2 Security Complex Car 28. Interview with Dr. E, Gaziantep, Turkey, 4. Eastern Aleppo city is referred to as “Aleppo” in the Bombings Kill Dozens, Syria Says,” New York July 25, 2015. remainder of this report. Any references to western Times, February 10, 2012, http://www.nytimes. 29. Interview with Dr. D, Gaziantep, Turkey, (government-controlled) Aleppo city or Aleppo com/2012/02/11/world/middleeast/blasts-in-aleppo- July 26, 2015. governorate are noted explicitly. syria--violence-said-to-continue.html. 30. Interview with Dr. L, Gaziantep, Turkey, 5. Physicians for Human Rights, “Anatomy of a Crisis: A 16. Chulov, Martin, “War for Aleppo: battle rages July 25, 2015. Map of Attacks on Health Care in Syria.” in city that will determine fate of Syria,” The 31. Interview with Dr. D, Gaziantep, Turkey, 6. UN Security Council Resolution 2139, passed on Guardian, August 4, 2012, http://www.theguardian. July 26, 2015. February 22, 2014, demanded that all parties to the com/world/2012/aug/04/aleppo-syria-civil-war; 32. Interview with Dr. L, Gaziantep, Turkey, conflict end attacks on civilian spaces, respect the Sengupta, Kim, “Ambushes and air strikes as July 25, 2015. principle of medical neutrality, and allow the free Syrian regime fight rebels street-by-street to gain 33. Ibid. passage of humanitarian aid across conflict lines. possession of Aleppo,” Independent, August 34. Interview with Dr. A, Gaziantep, Turkey, 7. UN Security Council Resolution 2165, passed on 3, 2012, http://www.independent.co.uk/news/ July 26, 2015. July 14, 2014, authorized the UN and its partner world/middle-east/ambushes-and-air-strikes-as- 35. Interview with Dr. K, Gaziantep, Turkey, organizations to deliver direct cross-border syrian-regime-fight-rebels-streetbystreet-to-gain- July 26, 2015. humanitarian aid to Syria from Turkey and Jordan possession-of-aleppo-7994450.html. 36. Interview with Dr. R, Gaziantep, Turkey, without the Syrian government’s consent. Prior 17. Solomon, Erika, “WRAPUP 6-Assad forces pound July 26, 2015. to the passage of this resolution, the UN was Aleppo, declare Damascus victory,” Reuters, July 29, 37. Interview with Dr. D, Gaziantep, Turkey, only permitted to send aid directly to the Syrian 2012,http://www.reuters.com/article/2012/07/29/ July 26, 2015. government, which would then distribute aid syria-crisis-idUSL6E8IS3RW20120729#BU02rrLvm 38. These definitions are based on interviews with almost exclusively to government-controlled areas. 1SDgseZ.97. various medical personnel, organizing bodies, and Resolution 2165 was renewed in December 2014 18. Médecins Sans Frontières, “Aleppo’s Reality: Daily funding organizations. The list of facilities is not with Resolution 2191. Life under Barrel Bombs,” March 2015, https:// meant to be comprehensive; it only covers the main 8. “In Syria, Demonstrations Are Few and Brief,” New www.doctorswithoutborders.org/sites/usa/files/ types of facilities functioning in Aleppo during the York Times, March 16, 2011, http://www.nytimes. attachments/aleppos_reality_daily_life_under_ summer of 2015. com/2011/03/17/world/middleeast/17syria.html. barrel_bombs.pdf. 39. The terms “field hospital” and “hospital” are used 9. Joshua, “ Founded by Seven 19. Aleppo City Medical Council, “Annual Report: Year interchangeably within this report. Generally, all Officers to Fight the Syrian Army,” Syria Comment, 2014,” March 2015, http://acmc-sy.org/wp-content/ hospitals in opposition-controlled territory are July 29, 2011, http://www.joshualandis.com/blog/ uploads/2015/08/ACMC%20Annual%20Report%20 considered “field hospitals.” free-syrian-army-established-to-fight-the-syrian- 2014_small.pdf. 40. Classification of these 10 medical facilities as field army/. 20. Lister, Charles, “As ISIS closes in, is it game over hospitals is controversial. One of these facilities is 10. White, Jeffrey, “Asad’s Armed Opposition: for Syria’s opposition in Aleppo?” CNN, August 15, considered by the supporting organization to be a The Free Syrian Army,” The Washington 2014, http://www.cnn.com/2014/08/15/opinion/ “polyclinic” rather than a field hospital. Because Institute, November 30, 2011, http://www. syria-aleppo-isis-threat/. polyclinics receive less funding than field hospitals washingtoninstitute.org/policy-analysis/view/ 21. Chulov, Martin and Julian Borger, “Syria: Isis do, this distinction has a large impact on the asads-armed-opposition-the-free-syrian-army. advance on Aleppo aided by Assad regime air hospital’s functionality. 11. “Over 240,000 killed since beginning of Syrian strikes, US says,” The Guardian, June 2, 2015, http:// 41. Aleppo Ministry of Health, “Health map for the city conflict,”Middle East Monitor, August 7, 2015, www.theguardian.com/world/2015/jun/02/syria- of Aleppo,” accessed November 3, 2015, http:// https://www.middleeastmonitor.com/news/middle- isis-advance-on-aleppo-aided-by-assad-regime-air- aleppo.moh.gov.sy/viewpage.php?page_id=98. east/20284-over-240000-killed-since-beginning-of- strikes-us-says. 42. Interview with Dr. C, Gaziantep, Turkey, July 28, syrian-conflict. 22. Snowball sampling (or chain sampling) is a non- 2015. 12. “World Refugee Day: Global forced displacement probability sampling technique where existing study 43. Hospitals’ capacities are generally stable as they tops 50 million for first time in post-World War II subjects recruit future subjects from among their depend on the size of the facility and the equipment era,” UNHCR, June 20, 2014, http://www.unhcr. acquaintances. available, which organizations try to maintain. org/53a155bc6.html. 23. Interview with Dr. A, Gaziantep, Turkey, However, due to attacks, inconsistent funding, and 13. Bakri, Nada, “Pro-Assad Rally Shows Syrian July 26, 2015. frequent repairs on equipment and infrastructure, Government Can Still Command Support,” New 24. Interview with Dr. E, Gaziantep, Turkey, each facility’s capacity can change overnight. York Times, October 19, 2011, http://www. July 25, 2015. 44. Interview with Dr. L, Gaziantep, Turkey, July 25, nytimes.com/2011/10/20/world/middleeast/assad- 2015; Interview with Dr. B, Gaziantep, Turkey, supporters-hold-rally-in-aleppo-syria.html. July 26, 2015. 45. Interview with Dr. L, Gaziantep, Turkey, July 25, 2015; Interview with Dr. S, Gaziantep, Turkey, July 26, 2015; Interview with Dr. F, Gaziantep, Turkey, July 27, 2015.

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46. E-mail communication with Dr. L, September 2015. 57. Interview with Dr. K, Gaziantep, Turkey, 79. Interview with Dr. E, Gaziantep, Turkey, 47. Interview with T, Gaziantep, Turkey, July 29, 2015. July 26, 2015. July 25, 2015. 48. Ibid. 58. Interview with Dr. H, Gaziantep, Turkey, 80. Skype interview with Dr. Y, August 28, 2015. 49. Interview with Dr. K, Gaziantep, Turkey, July 25, 2015. 81. Interview with Dr. S, Gaziantep, Turkey, July 26, 2015. 59. Interview with Dr. A, Gaziantep, Turkey, July 26, 2015. 50. This total number of “physicians” includes those who July 26, 2015. 82. Interview with Dr. L, Gaziantep, Turkey, completed all formal training in addition to those 60. Interview with Dr. K, Gaziantep, Turkey, July 25, 2015. who completed medical school but did not complete July 26, 2015. 83. Ibid. their residencies before the conflict broke out. A 61. Interview with Dr. S, Gaziantep, Turkey, 84. Interview with Dr. D, Gaziantep, Turkey, number of individuals who have not completed their July 26, 2015. July 26, 2015. residency training are now effectively working as 62. Interview with Dr. A, Gaziantep, Turkey, 85. Interview with Dr. A, Gaziantep, Turkey, physicians. At the beginning of the conflict, they July 26, 2015. July 26, 2015. acted as residents by observing operations and 63. Interview with Dr. K, Gaziantep, Turkey, 86. Interview with Dr. A, Gaziantep, Turkey, learning from fully trained physicians, but as the July 26, 2015. July 26, 2015; Interview with Dr. L, Gaziantep, conflict went on, these doctors had enough practice 64. Interview with Dr. L, Gaziantep, Turkey, July 25, Turkey, July 25, 2015. to work on their own, thus PHR has included them in 2015; Interview with Dr. K, Gaziantep, Turkey, July 87. Interview with Dr. N, Gaziantep, Turkey, the total count of physicians. 26, 2015; Interview with Dr. R, Gaziantep, Turkey, July 26, 2015. 51. Doctors interviewed estimated that prior to the July 26, 2015; Interview with Dr. A, Gaziantep, 88. Interview with Dr. A, Gaziantep, Turkey, conflict, there were approximately 1,500 doctors Turkey, July 26, 2015. July 26, 2015. practicing in what is now opposition-controlled 65. Interview with Dr. L, Gaziantep, Turkey, 89. Interview with Dr. D, Gaziantep, Turkey, eastern Aleppo city. July 25, 2015. July 26, 2015. 52. Interview with Dr. D, Gaziantep, Turkey, July 26, 66. Interview with Dr. B, Gaziantep, Turkey, 90. Maxillofacial surgery is a specialty of dentistry 2015. Interview with Dr. S, Gaziantep, Turkey, July 26, 2015. (requiring specialized training) that combines July 26, 2015. Interview with M, Gaziantep, 67. Syrian Arab Republic Ministry of Health Directorate dentistry and surgery to perform surgery on the Turkey, July 28, 2015. Skype interview with Dr. Y, of Planning and International Cooperation, Health face and jaw. August 28, 2015. Statistical Bulletin, Sixth edition, 2010. 91. Interview with Dr. K, Gaziantep, Turkey, 53. The World Bank, “Physicians (per 1,000 people)” 68. Interview with Dr. L, Gaziantep, Turkey, July 25, July 26, 2015. accessed November 3, 2015, http://data.worldbank. 2015; Interview with Dr. N, Gaziantep, Turkey, 92. Interview with Dr. L, Gaziantep, Turkey, org/indicator/SH.MED.PHYS.ZS; Interview with Dr. D, July 26, 2015; Interview with Dr. R, Gaziantep, July 25, 2015. Gaziantep, Turkey, July 26, 2015; Interview with Dr. Turkey, July 26, 2015. 93. Ibid. S, Gaziantep, Turkey, July 26, 2015; Interview with 69. Interview with Dr. H, Gaziantep, Turkey, 94. Interview with Dr. S, Gaziantep, Turkey, M, Gaziantep, Turkey, July 28, 2015; Skype interview July 25, 2015. July 26, 2015. with Dr. Y, August 28, 2015. 70. Interview with Dr. L, Gaziantep, Turkey, 95. Interview with Dr. D, Gaziantep, Turkey, 54. Email correspondence with Dr. D, August 2015. July 25, 2015. July 26, 2015. 55. Because there is often overlap in hospital staff 71. Interview with Dr. L, Gaziantep, Turkey, July 25, 96. Interview with Dr. H, Gaziantep, Turkey, (some staff work at more than one hospital), simply 2015; Interview with Dr. E, Gaziantep, Turkey, July July 25, 2015. counting the total number of physicians at each 25, 2015; Interview with Dr. D, Gaziantep, Turkey, 97. Interview with Dr. B, Gaziantep, Turkey, hospital would overstate the total. When it was July 26, 2015; Interview with Dr. N, Gaziantep, July 26, 2015. not known if physicians overlapped or not, a range Turkey, July 26, 2015; Interview with Dr. R, 98. Interview with Dr. L, Gaziantep, Turkey, was given. Gaziantep, Turkey, July 26, 2015. July 25, 2015; Interview with Dr. E, Gaziantep, 56. Aleppo City Medical Council, “Annual Report: Year 72. Interview with Dr. H, Gaziantep, Turkey, Turkey, July 25, 2015. 2014;” Interview with Dr. L, Gaziantep, Turkey, July July 25, 2015. 99. Interview with Dr. E, Gaziantep, Turkey, 25, 2015; Interview with Dr. D, Gaziantep, Turkey, 73. Interview with Dr. L, Gaziantep, Turkey, July 25, July 25, 2015. July 26, 2015; Interview with Dr. B, Gaziantep, 2015; Interview with Dr. A, Gaziantep, Turkey, July 100. Interview with Dr. A, Gaziantep, Turkey, Turkey, July 26, 2015; Interview with Dr. N, 26, 2015; Skype interview with Dr. Y, August 28, July 26, 2015. Gaziantep, Turkey, July 26, 2015; Interview with Dr. 2015. 101. Interview with Dr. H, Gaziantep, Turkey, R, Gaziantep, Turkey, July 26, 2015; Interview with 74. Sahloul, Zaher, “the Corridor of Death,” Foreign July 26, 2015. Dr. S, Gaziantep, Turkey, July 26, 2015; Interview Policy, March 4, 2014, http://foreignpolicy. 102. Interview with Dr. L, Gaziantep, Turkey, with Dr. A, Gaziantep, Turkey, July 26, 2015; Email com/2014/03/04/the-corridor-of-death. July 25, 2015; Interview with Dr. D, Gaziantep, communication with G, September 2015; Email 75. Bannerman, Lucy, “‘Assad’s snipers’ target unborn Turkey, July 26, 2015; Interview with Dr. R, communication with Dr. L, September 2015. babies,” The Times, October 19, 2013, http:// Gaziantep, Turkey, July 26, 2015; Interview with www.thetimes.co.uk/tto/news/world/middleeast/ Dr. K, Gaziantep, Turkey, July 26, 2015. article3898764.ece. 103. Interview with Dr. R, Gaziantep, Turkey, 76. Interview with Dr. D, Gaziantep, Turkey, July 26, 2015. July 26, 2015. 104. Ibid. 77. Interview with Dr. N, Gaziantep, Turkey, July 26, 2015; Interview with Dr. E, Gaziantep, Turkey, July 25, 2015. 78. Interview with Dr. D, Gaziantep, Turkey, July 26, 2015; Interview with Dr. A, Gaziantep, Turkey, July 26, 2015.

24 Aleppo Abandoned: A Case Study on Health Care in Syria 105. Interview with Dr. R, Gaziantep, Turkey, 126. Interview with Dr. B, Gaziantep, Turkey, 141. “Russian military forces start airstrikes in July 26, 2015; Interview with Dr. A, Gaziantep, July 26, 2015. Syria - Ministry of Defense,” Russia Today, Turkey, July 26, 2015; Interview with Dr. F, 127. Assessment Working Group for Northern Syria, September 30, 2015, https://www.rt.com/ Gaziantep, Turkey, July 27, 2015. “Joint Rapid Assessment of Northern Syria: news/317042-russia-start-operation-syria/. 106. Interview with Dr. L, Gaziantep, Turkey, Aleppo City Assessment,” March 28, 2013, http:// 142. Shaheen, Kareem, “Syrian troops launch ground July 25, 2015. reliefweb.int/sites/reliefweb.int/files/resources/ offensive backed by Russian airstrikes” The 107. Interview with Dr. F, Gaziantep, Turkey, Aleppo%20Assessment%20Report.pdf; Assistance Guardian, October 7, 2015, http://www.theguardian. July 27, 2015. Coordination Unit, “Periodic Needs Assessment com/world/2015/oct/07/russian-jets-pound-syrian- 108. Ibid. Report: The Dynamo - Aleppo Province,” July provinces-in-fresh-wave-of-attacks-says-watchdog; 109. Interview with Dr. N, Gaziantep, Turkey, 2015, http://reliefweb.int/sites/reliefweb.int/files/ Abdulrahim, Raja, “Syrian Regime, Backed by July 26, 2015. resources/Report-Dynamo-Micro_final_290715_ Russia, Iran and , Expands Ground 110. Interview with Dr. R, Gaziantep, Turkey, Dynamo_RPT_ENG_P.pdf. Offensive to Aleppo,” The Wall Street Journal, July 26, 2015. 128. Interview with Dr. L, Gaziantep, Turkey, October 18, 2015, http://www.wsj.com/articles/ 111. Interview with Dr. A, Gaziantep, Turkey, July 25, 2015. syrian-regime-backed-by-russia-iran-and-hezbollah- July 26, 2015. 129. Interview with Dr. E, Gaziantep, Turkey, expands-ground-offensive-to-aleppo-1445206886. 112. Interview with Dr. E, Gaziantep, Turkey, July 25, 2015. 143. “Chief of the Main Operational Directorate of the July 25, 2015; Interview with Dr. D, Gaziantep, 130. Interview with Dr. C, Gaziantep, Turkey, General Staff of the Russian Armed Forces Andrei Turkey, July 26, 2015. July 28, 2015. Kartapolov summed up results of the actions of 113. Interview with Dr. N, Gaziantep, Turkey, 131. Ibid. the Russian air group in Syria,” Ministry of Defence July 26, 2015. 132. Interview with Dr. H, Gaziantep, Turkey, of the Russian Federation, September 30, 2015, 114. Interview with Dr. A, Gaziantep, Turkey, July 25, 2015; Interview with Dr. A, Gaziantep, http://eng.mil.ru/en/news_page/country/more. July 26, 2015. Turkey, July 26, 2015; Interview with G, Kilis, htm?id=12062538@egNews. 115. Interview with Dr. H, Gaziantep, Turkey, Turkey, July 29, 2015. 144. The Carter Center, “Syria Conflict Update,” October July 25, 2015; Interview with Dr. A, Gaziantep, 133. Interview with Dr. N, Gaziantep, Turkey, 30, 2015, http://www.cartercenter.org/resources/ Turkey, July 26, 2015; Interview with Dr. J, Kilis, July 26, 2015. pdfs/peace/conflict_resolution/syria-conflict/Syria- Turkey, July 29, 2015. 134. Interview with Dr. B, Gaziantep, Turkey, Conflict-Update-103015.pdf. 116. Interview with Dr. J, Kilis, Turkey, July 29, 2015. July 26, 2015. 145. Physicians for Human Rights, “Russian forces 117. Interview with Dr. H, Gaziantep, Turkey, 135. Interview with Dr. E, Gaziantep, Turkey, Carried Out at Least 10 Attacks on Medical Facilities July 25, 2015. July 25, 2015. in Syria in October,” November 16, 2015, http:// 118. Interview with G, Kilis, Turkey, July 29, 2015. 136. Interview with Dr. R, Gaziantep, Turkey, physiciansforhumanrights.org/press/press-releases/ 119. Ibid. July 26, 2015. russian-forces-carried-out-at-least-10-attacks-on- 120. Interview with Dr. A, Gaziantep, Turkey, 137. Interview with Dr. E, Gaziantep, Turkey, medical-facilities-in-syria-in-october.html. July 26, 2015. July 25, 2015. 146. The Carter Center, “Syria Conflict Update.” 121. Interview with Dr. E, Gaziantep, Turkey, 138. Interview with Dr. N, Gaziantep, Turkey, July 25, 2015; Interview with Dr. R, Gaziantep, July 26, 2015. Turkey, July 26, 2015. 139. Ibid. 122. Interview with Dr. L, Gaziantep, Turkey, 140. Gordon, Michael R. and Eric Schmitt, “Russian July 25, 2015. Moves in Syria Pose Concerns for U.S.,” New York 123. Ibid. Times, September 4, 2015, http://www.nytimes. 124. Interview with G, Kilis, Turkey, July 29, 2015. com/2015/09/05/world/middleeast/russian-moves- 125. Interview with Dr. C, Gaziantep, Turkey, in-syria-pose-concerns-for-us.html; “Russia ramps July 28, 2015; Interview with G, Kilis, Turkey, up military buildup in Syria,” CBS News, September July 29, 2015. 21, 2015, http://www.cbsnews.com/news/ russia-ramps-up-military-buildup-in-syria/.

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