Qualitative accounts from Syrian health professionals regarding violations of the right to health, including the use of chemical weapons, in opposition-held Syria

Abstract

ObjectivesTo explore the impact of the conflict, including the use of chemical weapons, in Syria on healthcare through the experiences of health providers using a public health and human rights lens.DesignA qualitative study using semi-structured interviews conducted in-person or over Skype using a thematic analysis approach.SettingInterviews were conducted with Syrian health workers operating in opposition-held Syria in cooperation with a medical relief organisation in Gaziantep, Turkey.ParticipantsWe examined data from 29 semi-structured in-depth interviews with a sample of health professionals with current or recent work-related experience in opposition-controlled areas of Syria, including respondents to chemical attacks.ResultsFindings highlight the health worker experience of attacks on health infrastructure and services in Syria and consequences in terms of access and scarcity in availability of essential medicines and equipment. Quality of services is explored through physicians’ accounts of the knock-on effect of shortages of equipment, supplies and personnel on the right to health and its ethical implications. Health workers themselves were found to be operating under extreme conditions, in particular responding to the most recent chemical attacks that occurred in 2017, with implications for their own health and mental well-being.ConclusionsThe study provides unique insight into the impact war has had on Syrian’s right to health through the accounts of a sample of Syrian health professionals, with continuing relevance to the current conflict and professional issues facing health workers in conflict settings.

Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria

“…Results contribute to the literature on how health-workers persevere in dangerous working and living conditions. As in other publications, participants described serious violations of the sanctity of health by combatants during the conflict 14 48. Key aspects health-workers reported as strengthening their ability to cope were knowing their families were safe, feeling valued and part of a team, appreciating the everyday joys in life and finding ways to maintain hope.…”

“…However, ICRC recommendations do not cover systematic air strikes against health facilities, and may be more appropriate for less severe conflicts. Other literature proposes documenting facility attacks more reliably and reducing biased self-reports, to discourage future perpetrators 18 48 56. We found a gap in the health literature regarding evidence on operational protective measures, possibly due to the challenges in conducting such research, and more could be learnt from the military medical literature.…”

“…This is the first study to examine adaptations to siege and targeting in Syria from the perspective of Syrians who have remained in their country during the conflict to try to relieve suffering. As noted by Footer et al , these local health-workers have received far less research attention than have international humanitarian workers 48. Similar research examines healthcare provision in besieged Gaza,41 health and nutrition in besieged settings49 50 and health-worker experiences in opposition-controlled areas 48…”

Conflict-Related Population Health Research in Syria, 2011-2019: An Assessment of Information Gaps, Research Needs and Challenges, for The Lancet - AUB Commission on Syria

“…Additional interventions and program evaluations included delivery and evaluation of an intervention through provision of information and follow-up questionnaire in bread packages being distributed by a humanitarian organization in Northern Syria (El-Khani, Cartwright et al 2016), evaluation of three modes of food assistance programming in Idlib in 2014-15 (Doocy, Tappis et al 2017), evaluation of an International Rescue Committee cash assistance program on violence against women in Raqqa (Blackwell, Casey et al 2019), evaluation of effectiveness of multi-level WASH risk reduction interventions in southern Syria in 2018 (Sikder, Daraz et al 2018) and examination of the impact of a psychosocial support program on the wellbeing of a control and intervention group of farmers (Ziveri, Kiani et al 2019). Several papers interviewed humanitarian workers, including humanitarian health staff working on non-communicable disease (NCD) care in Syria (Garry, Checchi et al 2018) and those involved in the cross-border humanitarian health response from Turkey (Duclos, Ekzayez et al 2019, Fradejas-Garcia 2019).Fourteen papers research health issues related to war strategies and alleged IHL violations, including an expert panel review of YouTube videos following a sarin gas attack(Rosman, Eisenkraft et al 2014) and interviews with healthcare workers in opposition-controlled areas regarding attacks on healthcare and challenges and experiences in responding to chemical attacks(Footer, Clouse et al 2018). Other research in this theme examined attacks on health care(Elamein, Bower et al 2017, Fouad, Sparrow et al 2017, Haar, Risko et al 2018, Wong and Chen 2018, Ri, Blair et al 2019), areas under or the effects of siege (Sahloul, Salem et al 2017, Morrison 2018, Fardousi, Douedari et al 2019), and war-related mortality (Guha-Sapir, Rodriguez-Llanes et al 2015, Chen, Shrivastava et al 2018, Guha-Sapir, Schlüter et al 2018, Ri, Blair et al 2019) including a study of characteristics of deceased victims of a chemical weapons attack (Rodriguez-Llanes, Guha-Sapir et al 2018).Mortality is the subject of ten papers, which report mortality counts provided by key informants in contested and opposition areas(Diggle, Welsch et al 2017); examine mortality data documented by the Violations Documentation Centre (VDC) (Guha-Sapir, Rodriguez-Llanes et al 2015, Guha-Sapir, Schlüter et al 2018, Rodriguez-Llanes, Guha-Sapir et al 2018)), examine associations between attacks on healthcare and civilian casualties(Ri, Blair et al 2019) or con rm con ict events in a fake-news data set (Abu Salem, Al Feel et al 2019); use capture-recapture methods on four data sets to estimate mortality in two governorates(Price, Gohdes et al 2015); estimate the number of unique identi able deaths by deduplicating four data sets(Chen, Shrivastava et al 2018); use spatio-temporal death data to forecast con ict events(Fujita, Shinomoto et al 2017) and report on a household survey of IDPs in Raqqa and retrospective one-year mortality, largely con ict-related deaths(Vernier, Cramond et al 2019).…”

I had to leave. I had to leave my clinic, my city, leave everything behind in Syria. Qualitative accounts from Syrian health care workers migrating from the war-torn country

“…[1,21] Most analyses of violence against health care in Syria have focused on damage to health care infrastructures, such as hospitals and ambulances. [22][23][24] Few studies have looked at HCWs personal experiences in conflicts [15,25], and none of them examines the reasons for HCWs leaving specifically Syria. Also, current reviews do not take into account how the violence by different warring parties, such as arrests, detention and kidnappings, affect the decision to leave to protect their own life and family members.…”