BEIRUT – On March 25, a helicopter dropped a bomb at the entrance of Latamneh hospital in northern Hama governorate, killing two people. Several other patients and staff at the Doctors Without Borders (MSF)-supported hospital suffered symptoms “consistent with an attack using chemicals.” Among the fatalities was Dr. Darwish, one of the three remaining orthopedic surgeons for the area’s some 120,000 people.

Dr. Darwish is one of hundreds of doctors and medical personnel who have been killed since the war began in Syria. Between March 2011 and February 2017 – just one month before Dr. Darwish’s death – at least 814 medical personnel were killed in Syria, according to a new report from the Lancet Commission on Syria led by the Faculty of Health Sciences at the American University of Beirut (AUB).

Fourteen experts on healthcare in Syria came together in December 2016 to form the Commission on Syria: Health in Conflict, in the hopes of responding to the crisis using “science and advocacy.”

Their first report, published on March 14, focuses on “steps that can support our health workers in Syria,” said Dr. Samer Jabbour, an associate professor of public health practice at AUB and a researcher on the commission.

Syria Deeply spoke with Dr. Jabbour about their initial findings on the state of Syrian health workers and the commission’s scientific approach to researching the weaponization of healthcare in Syria.

Syria Deeply: What was the most surprising thing to come out of your research for this report?

Samer Jabbour: Perhaps most surprising to us, as well as the readership, is how early the violations started and how long these violations have persisted with inadequate international response. This is the key message we wanted to convey from our analysis of weaponization. [These points] have profound implications for what inaction can mean in terms of enlargement of scopes of crimes.

Syria Deeply: Yet, six years later, no one has been able to do anything to stop it. What would have to happen for this to stop and for the perpetrators to be held accountable?

Jabbour: There is no other way but for all those interested, all those who are committed to the cause of justice, to continue to put pressure. This conflict has become unusually regionalized and internationalized, but we must continue to pressure.

It is encouraging that the U.N. Security Council adopted the resolution on protection of health workers. We know that that resolution was not respected, even by members of the U.N. Security Council, but we think that it is a step in the right direction. We just need to continue to push in order for these norms and international laws to be respected.

Syria Deeply: How does the situation in opposition-held areas compare to the health situation in government-controlled areas?

Jabbour: We have not focused on that aspect at length [but according to our assessment], government controlled areas have significant variability in terms of provision of care. Areas like Damascus or the coastal areas enjoy a good supply of healthcare, both in the public sector and the private sector, although issues of access especially in the private sector is a problem. There are some other government controlled areas, especially in the east, that continue to suffer from inequality, which had suffered from even before the conflict.

Syria Deeply: Is the idea of forcing civilians or healthcare providers to move to government-held areas where the healthcare system is better part of the weaponization strategy?

Jabbour: We do not include this in the article, but effectively, it is a result of the pressure that non-government controlled areas are under. People have to move to a safer place and we have examples of many health providers moving to government controlled areas.

That is not really the prime purpose of weaponization. The prime purpose is to deprive non-government controlled areas of healthcare, to punish health facilities and health workers who are providing care to the injured in those areas where everyone is labeled as terrorists, and really depriving people, particularly in the besieged areas, of access to vital medicines and supplies.

Syria Deeply: How did you go about gathering the plethora of information and statistics presented in the report that?

Jabbour: We have attempted what we call a triangulation approach. We collected data from multiple sources in Syria, including the Syrian Network for Human Rights, Physicians Human Rights (PHR), SAMS [Syrian American Medical Society Foundation], the Violations Documentation Center. The reason for this is a lot of resources, and lot of private reports typically use one source.

We thought it was important to triangulate in order to strengthen the size base for any reporting and add on to what we have from any one source. This is clearly demonstrated through the numbers of health workers killed, because the PHR [data] only goes up to September of 2016, so after that, we had to get from others. We also wanted to use international and local sources, and ensure that we report from Syria-based organizations that have a track record of documenting violations.

Syria Deeply: Did you have any difficulties in getting this information or in getting people to discuss the situation?

Jabbour: The information gathered for the article was all collected in confidential, anonymous ways. It was dealt with in scientific ways that are protected, so we did not have any particular problems.

We would have liked to have access to a larger input from both government and non-government controlled areas, but this the next step of inquiry for the commission. This is a really preliminary inquiry that summarizes the input that we were able to gather by the time of the publication. The commission’s final report in 2018 will look at a broad range of thematic areas including health profiles inside Syria, the health of refugees in neighboring countries and beyond, the international response to the crisis and developing a clear way forward in terms of future implications for Syria as well as the broader field of conflict of health.

Syria Deeply: How does the health situation in Syria compare to conflicts that have come before it or current conflicts in different countries?

Jabbour: We make a very strong statement that the extent of targeting of health facilities’ own workers and the level of weaponization that we have seen in the Syria crisis is unprecedented. We’ve not seen this in any prior war. Prior wars have seen criminalization of medical neutrality, attacks on health workers and health facilities, but the systematic, deliberate and widespread use of the strategy with the intention to shut down care [in Syria] really is unprecedented.

This aspect of the Syria crisis sets a very dangerous precedent. The lack of action from the Syria response means that this strategy is open for future use. This is very bad for the world, not just for our region.

Syria Deeply: In so many different ways Syria has set a terrible precedent for the future. In terms of next steps for those who are in Syria, what is the most pressing issue or issue that should be tackled first?

Jabbour: With regards to the international community, we are calling for strengthening accountability, and to implement the U.N. Security Council resolution on the protection of health workers and the U.N. General Assembly resolution on investigating and prosecuting war crimes. This is the priority, so that the world is held to its words.

In terms of our Syrian colleagues, we are calling for the strengthening of the support framework, whether through trainings, supplies or multiple other actions that hopefully will support our health workers.

Syria Deeply: So many doctors have fled and so many of the younger medical practitioners haven’t had time to finish school and are now forced to work across several different fields. Would training be a main focus for the Syrian contingent?

Jabbour: It is one important aspect that has been conveyed to us as a crucial area. A lot of training already takes place. SAMS and other organizations and international missions support the skill building, task shifting and [alleviate the] overwork of Syrian workers.

This is a vast need. One important aspect that the international community can do today is to ensure this is addressed in a far more systematic way, is to [develop] a whole program of scaling-up capacities, rather than occasional training activities here and there, that is important and sufficient to address the needs.

Syria Deeply: This report used a scientific approach to presenting the findings, which is different from many other reports on human rights abuses in Syria. Will this approach be able to convince people who might not believe these abuses are happening, or those who have refuted such claims in the past?

Jabbour: This is a very good question. It’s also a very difficult question because we have all witnessed early polarization in relation to the opposing parties to the conflict in Syria. We are not sure that our report will change such polarization.

What we do hope to do is that the report and the ongoing work of the commission will be able to fill an important gap in the scientific investigation of the Syria conflict and that it will mobilize a greater global health community to bear pressure in this area. Consequently, we hope that this work will eventually be able to make a difference in the lives of people in Syria, including health workers. That’s all I could hope for.

The interview has been edited for length and clarity.

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