Among the most dangerous places to work or visit in Syria are hospitals. Medical facilities have come under attack hundreds of times since conflict started in 2011, forcing some doctors and other health care personnel to move underground.
After years of appeals for parties to abide by international humanitarian law failed to stop the violence, members of the health cluster in Syria sought a new ally: data. If the information about attacks was rigorous enough, humanitarians hoped, the international community could take a stand.
The first results of that experiment were described in more detail in an article published in the Lancet last week. The Syria response health cluster in Turkey, composed of U.N. agencies and about 50 international NGOs, including those based in Turkey and Syria, piloted a combined mobile phone and online-based tool to report and verify attacks. Data is triangulated between sources to confirm its veracity.
“The data is robust enough to take actions if [the] international community is willing to do so,” said Dr. Alaa Abou Zeid, health cluster coordinator for WHO in Yemen and one of the authors of the Lancet report.
The effort speak volumes of the realities on the ground for health care in Syria, and on how humanitarian actors are trying every avenue and means possible to bring to a halt what many refer to as the “weaponization” of health care in the country.
The network of medical and aid workers involved now “have hopes” that the information will force armed parties in the conflict in Syria to change course, although they are “not confident seeing the course of war in Syria over the past 6-7 years.”
If not a change on the ground, investigators hope to lay the groundwork for a later investigation into possible war crimes. The data tool doesn’t capture information on perpetrators of the attack, or whether it was carried out intentionally, out of negligence, or taken without an advance warning. But it does provide a starting point.
“We provide the facts about the attack so other specialized agencies and intergovernment bodies can conduct the investigation to identify perpetrators,” Zeid said. This, he added, “was much needed to pave the road and provide robust data to any possible investigation.”
Under international humanitarian law, health facilities are neutral grounds during war and conflict and should be spared from attacks or violence. But since the beginning of the conflict in Syria, health care facilities have suffered bombardments and attacks, injuring and killing patients and health care workers.
By May 2016, the rise in attacks against health care in Syria and elsewhere inspired the U.N. Security Council to pass Resolution 2286, condemning attacks against the wounded and sick, medical personnel and health facilities.
The situation on the ground, however, moved in the opposite direction. The number of bombardements rose after the resolution, according to a report early this year by the Syrian American Medical Society, a nonprofit providing humanitarian and medical assistance in Syria, as well as to Syrians who have fled to neighboring countries.
The Safeguarding Health in Conflict Coalition released its latest findings on attacks on health care workers and facilities from 2016, showing a continued "widespread and extremely serious problem.
SAMS has been documenting attacks on health care in Syria based on first-hand accounts of staff supplemented with photo documentation. Its report found that the rate of attacks against hospitals and health care workers in Syria increased by 89 percent following the UNSC resolution in 2016. Russian intervention in Syria has largely contributed to the increase, according to the report.
“In 2015, the rate of targeting of medical facilities and personnel was once every four days. In October , following Russia’s intervention in Syria in support of the Syrian government, this rate doubled to one attack every 48 hours,” according to the report.
Documenting the damage
Despite the clear rise in attacks, claims and counterclaims have often proven difficult to verify in the fog of Syria’s battlefields. The health cluster hoped more reliable data based on a standardized methodology might break the impasse.
They turned to a tool developed by the World Health Organization, called the Monitoring Violence against Health Care. MVH was developed in response to a 2012 World Health Assembly resolution asking the U.N. aid agency to develop a method to collect more reliable evidence on attacks against health care.
The Lancet article describes how the health cluster made use of Whatsapp to alert its network, composed of 293 members, of an attack. This initial information was often brief; details were expounded further and completed in an “anonymous and confidential online alert form” that identified the location of the attack, mode of attack, type of facility, and the extent of the damage suffered, including who and how many were injured and killed.
What separated this reporting from others was its adherence to a triangulated verification process. The team behind MVH specifically matches information on date of attack, time, location, facility, service targeted and health facility code.
For each incident, the methodology only considered information from those who were able to visit the site of the attack or were present during the incident.
Devex spoke with Khaula Sawah, CEO of the Union of Medical Care and Relief Organizations USA, one of the few Syrian-led medical organizations still operating across the war-torn country, about challenges in the field and how the conflict has shaped the delivery of care.
Next, the report goes through a process of data cleaning and information matching before being considered valid. A reported incident is considered verified only when backed with similar evidence from another member of the health cluster and from a member of the non-health cluster that also does their own information gathering and verification process.
In cases when data on casualties didn’t match, but the report was still considered verified as it matches most of the key variables mentioned, the MVH team considered the lower number of casualties reported.
Between Nov. 2015 and Dec. 2016, out of 402 reported attacks affecting health care, 158 were considered verified. More than half of the verified attacks were on health care facilities providing trauma care.
A large proportion of the attacks were through aerial bombardment. A total of 157 people were killed during this period, and 437 were wounded, based on verified incidents.
All 11 hospitals in the governorates of Dar’a and Quneitra have been attacked at least once, while five of Aleppo’s 57 hospitals have experienced more than five attacks in the same period. Data revealed zero attacks in hospitals in the Syrian government-controlled cities of Damascus and Tartous, although this could be due to underreporting or lack of health partners in the vicinity to verify information, according to the report.
Further analysis on the attacks’ impact on people’s health outcomes and their access to health services are underway, according to the report.
The “most pressing challenge” for the team managing the MVH tool is convincing its partners to continue reporting attacks, which appear to go on unabated. So far, better data hasn’t created any momentum for change. Indeed, in the first quarter of 2017, the WHO reported 37 verified reports of attacks against health care facilities in Syria, resulting in the deaths of 10 health workers.
“It creates a lot of frustrations,” said Zeid. “We keep encouraging them to report and explain the importance of advocacy. Otherwise, silence will not help anyone.”
Jenny Lei Ravelo is a Devex senior reporter based in Manila. Since 2011, she has covered a wide range of development and humanitarian aid issues, from leadership and policy changes at DfID to the logistical and security impediments faced by international and local aid responders in disaster-prone and conflict-affected countries in Africa and Asia. Her interests include global health and the analysis of aid challenges and trends in sub-Saharan Africa.
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