The “weaponisation” of healthcare in Syria, involving the targeted destruction of medical facilities and the killing of hundreds of healthcare workers, is unprecedented and has profound and dangerous implications for medical neutrality in conflict zones, according to an authoritative study.

“Syria has become the most dangerous place on earth for healthcare providers,” say the researchers involved. Their study of the attacks on healthcare in Syria since 2011, published by the Lancet medical journal, reveals that the death toll among medical workers is at least 814. Some of those health workers were tortured and executed.



There were nearly 200 attacks on healthcare facilities in 2016 alone, say the researchers in their first report for the Lancet Commission on Syria, led by the Faculty of Health Sciences at the American University of Beirut.

The authors define what they call the weaponisation of healthcare in Syria as a situation “in which healthcare facilities are attacked, workers are targeted, medical neutrality is obliterated and international humanitarian laws are violated to restrict or prevent access to care as a weapon of war”.

They criticise UN agencies and the international community for failing to hold the aggressors, who are breaking international conventions, to account.

“The application of this strategy in the Syria conflict, largely by pro-government forces and allies, with limited consequences for perpetrators has profound implications for health protection,” they write.

Doctors and other medical staff are having to practise “siege medicine”, improvising to help trauma victims, women in labour or patients suffering from infectious diseases with severe shortages of supplies.

Operations are carried out using the light from mobile phones while health workers have devised ways to make some of the essentials, such as saline, since intravenous fluids are routinely removed from aid convoys allowed in to blockaded cities.

“There is now an underground factory in eastern Ghouta near Damascus producing normal saline,” the authors write. “Denied blood bags for the collection and storage of blood, urine bags with anticoagulants added are used.”

Some medical facilities have been repeatedly bombed in an apparent attempt to close them down. Kafr Zita cave hospital in Hama has been bombed 33 times since 2014, including six times so far in 2017. M10, an underground hospital in eastern Aleppo, was attacked 19 times in three years and completely destroyed in October 2016.

“Over time, targeting has become more frequent, more obvious, and more geographically widespread. To the best of our knowledge, this level of targeting health facilities has not occurred in any previous war, and the data we were able to collect overwhelmingly show intent to target, which falls under the definition of a war crime,” says Dr Samer Jabbour, co-chair of the commission and associate professor of public health practice at the university’s faculty of health sciences.

In 2009, there were 29,927 doctors in Syria. Between 2011 and 2015, an estimated 15,000 doctors left the country. The effect on civilians is profound, says the paper.

“Based on data from 2,100 key informant interviews in 698 subdistricts in both government-controlled and non-government-controlled areas, only 42% of the population live in areas that are likely to have sufficient health workers, whereas 31% live in areas where health workers are insufficient and 27% live in areas where health workers are completely absent.”

The report comes on the sixth anniversary of the conflict, which grew out of the 2011 Arab Spring protests. Two separate reports also reveal the extent of the atrocities committed in Syria. The UN’s Independent International Commission of Inquiry on Syria accused government forces and their allies of showing a “complete disregard for civilian life and international law” through continued use of cluster munitions, incendiary weapons and chlorine gas as weapons of war. Separately, a Physicians for Human Rights report accused the Syrian government of wilfully denying international shipments of food and medicine to millions of Syrians in besieged areas.

Targeting of healthcare workers started well before the current conflict, says the paper. The first documented execution of a doctor by pro-government forces was in March 2011. The following month, Syrian forces started arresting doctors, patients and paramedics in Douma and other areas of eastern Ghouta, where protests took place.



In July 2012, the Syrian government passed a law that in effect criminalised the provision of medical care to anyone injured by pro-government forces in protest marches against the government. It was “an effort to justify the arrests, detention, torture, and execution of health workers” and similar to one passed by Serbia in the 1998-99 war in Kosovo.

The targeting of healthcare workers continues, most often by government forces although abuses by opposition forces have also been reported, they say.

Jabbour said the attacks on health facilities and workers, violating international law, are designed to deprive the population of care as a means of control. “The international community has left these violations of international humanitarian and human rights law largely unanswered, despite their enormous consequences.

“There have been repudiated denunciations, but little action on bringing the perpetrators to justice. This inadequate response challenges the foundation of medical neutrality needed to sustain the operations of global health and protect health workers in situations of armed conflict.”