Hospitals Become the Front Line in the Syrian Civil War

And aid groups say U.S. budget cuts may endanger doctors and further fuel the migrant crisis.

A wounded Syrian girl looks on at a make shift hospital in the rebel-held area of Douma, east of the capital Damascus, following shelling and air raids by Syrian government forces on August 22, 2015. At  least 20 civilians and wounded or trapped 200 in Douma, a monitoring group said, just six days after regime air strikes killed more than 100 people and sparked international condemnation of one of the bloodiest government attacks in Syria's war.   AFP PHOTO / ABD DOUMANY / AFP / ABD DOUMANY        (Photo credit should read ABD DOUMANY/AFP/Getty Images)
A wounded Syrian girl looks on at a make shift hospital in the rebel-held area of Douma, east of the capital Damascus, following shelling and air raids by Syrian government forces on August 22, 2015. At least 20 civilians and wounded or trapped 200 in Douma, a monitoring group said, just six days after regime air strikes killed more than 100 people and sparked international condemnation of one of the bloodiest government attacks in Syria's war. AFP PHOTO / ABD DOUMANY / AFP / ABD DOUMANY (Photo credit should read ABD DOUMANY/AFP/Getty Images)

Mahmoud Hariri, a surgeon born and raised in Syria, has lost track of how many times his hospital in Aleppo has been bombed since the Syrian civil war began in 2011.

He’s seen patients die on operating tables during attacks. One patient pulled a tube out of his own body to flee a hospital as it was bombed. Once, while Hariri was visiting a nearby medical facility, it too was bombed. As he fled, he discovered a human brain on the street outside. He picked it up, put it in a small box, and later returned it to the hospital.

The intensive care unit is especially nightmarish during an attack. “You have to bring trolleys and bring unconscious patients out,” Hariri explained in a phone interview with Foreign Policy magazine. “There are no elevators to bring the patients down, so you are carrying them down the stairs.”

The intentional destruction of hospitals is one of the most important factors driving Syrians out of their country, fueling the largest global migrant crisis since World War II. To save patients and medical workers, staff have moved entire hospitals underground into basements and caves, constructing military-like fortifications to try to keep operating even as the bombs keep falling.

“Healthcare in Syria has been weaponized,” said Kathleen Fallon, a co-author of the Syria Campaign report, speaking at an event hosted by the Middle East Institute in Washington, DC. “Field hospitals inside of Syria have quite literally been driven underground into caves and into basements.”

But now those efforts could be endangered. U.S. and U.N. grants have helped make these expensive protections possible, but USAID faces drastic budget cuts as part of President Donald Trump’s America First platform. As a result, aid groups worry that reduced funding will put innocent lives at risk, exacerbate the refugee crisis, and allow extremist groups to fill the void.

The Syrian civil war is the 21st century’s deadliest conflict so far, with more than 450,000 killed and 12 million displaced. More than 4.8 million Syrians have fled the country, pouring into neighboring countries and Europe.

In addition to military campaigns against rebel groups, Syrian President Bashar al-Assad’s forces have deliberately targeted medical facilities, schools, and infrastructure throughout opposition-held regions. Since 2011, 454 strikes have targeted 310 medical facilities, according to a May 2016 report released by the Syria Campaign, an advocacy group that works to protect Syrian civilians. Assad regime and Russian forces were behind 91 percent of those attacks, according to the report; the Islamic State sometimes kidnaps doctors but has no airforce capable of aerial assaults.

Those attacks on hospitals dramatically increased in frequency once Russia waded into the fray in the fall of 2015. In April, one medical facility was attacked every 29 hours. The more Syrian hospitals burrowed underground seeking protection, the harder Russian forces sought to hit them.

They aren’t aberrations. The attacks are part of a total assault on civilian life in rebel-held areas.

“They’re targeting schools, they’re targeting infrastructure. They’re targeting life — the very basic needs of life,” said Jomana Qaddour, co-founder of Syria Relief and Development, a nonprofit which has operated humanitarian programs in Syria since 2011, in an interview with FP. Civilians must live near places where they can access the basic necessities of life, Qaddour explained, and in the middle of a war, medical care is a top priority.

By targeting hospitals, regime forces are destroying lifelines and forcing people out of their homes. “They want to make it impossible for people to live outside of government-held areas,” Qaddour said.

To protect against attacks, aboveground hospitals added layer after layer of fortifications. Workers created “sacrificial” floors, empty floors at the top of the building that will absorb the brunt of any aerial assault. They built concrete walls around the hospital, strengthened building frames to prevent collapse, and covered windows with sandbags.

But the safest approach is simply to dig, to go deep into basements or natural caves, or even build whole new facilities underground. A cave hospital can cost up to $800,000, and an underground facility up to $1.5 million, according to the report. But that’s more cost-effective than rebuilding destroyed facilities — especially since priceless medical equipment is often destroyed as well. There are currently four cave hospitals in opposition-held regions in Syria and 21 underground hospitals. The majority of hospitals still use only sandbags, or have no fortifications at all.

As hospitals have strengthened their walls and moved underground, however, Syrian regime and Russian forces have deployed bunker-busting bombs and chemical weapons to blast through fortifications and suffocate those trapped underground.

“When we saw hospitals move in the direction of completely underground was when the Russian involvement in Syria escalated, “ said Qaddour. “When Russians started bombing, we even saw different kinds of missiles being used…able to penetrate much further.”

“On Christmas Day in 2015, the Russians hit our hospital twice,” said Qaddour. “They hit it once, waited for rescue workers like white helmets to come, and hit it again.”

Chemical weapons can also turn underground and cave hospitals into death traps, as medical staff and patients at Latamnah Hospital, an underground facility in the western Syrian city of Hama, learned on March 25, 2017. When bombs containing an airborne poison landed at the hospital’s entrance, the toxic agent spread throughout the underground structure. Ali Darwish, an orthopedic surgeon, was in the middle of an operation when the bombs hit. He chose to continue operating, rather than flee with other medical staff. He later died.

Funding and support for Syrian hospitals comes from numerous non-governmental organizations with operations on the ground. These groups, in turn, rely in part on government grants, including from USAID’s Office of Foreign Disaster Assistance.

Yet according to a copy of the Trump administration’s 2018 budget proposal obtained by FP, the plan is to gut foreign direct assistance, slashing support for foreign missions and in some cases zeroing out budgets for certain programs.

While Congress is very unlikely to agree to all the cuts, many USAID programs will face fiscal pressure in the coming year. The budget proposal is an indication that Trump isn’t afraid to end America’s long history of generous foreign aid, even though experts warn such a move would be counterproductive. Andrew Natsios, former USAID Administrator under President George W. Bush, predicted it would be an “unmitigated disaster for the longer term.”

The 2018 Budget will allow the United States to retain a leadership role in shaping global humanitarian assistance and will continue to allow for funding of needs in Syria and other crisis areas while also asking the rest of the world to increase their share,” a USAID spokesperson told FP. The spokesperson also said that the budget aims to improve the “efficiency and effectiveness” of humanitarian programs.

For an administration eager to check Syrian immigration, cutting funding to aid groups would seem to be counterproductive. The link between refugee flows and hospital bombings is well-established, said  Basel Termanini, vice president of the Syrian American Medical Society, a Washington-based nonprofit that supports 1,866 medical workers and 139 medical facilities around parts of Syria that are beyond the control of Assad or the Islamic State.

Termanini said that after the last hospital in eastern Aleppo was destroyed in late 2016, a wave of people left the city.

“Without the United States as the most generous donor in the funding space, the conditions on the ground are only going to get worse,” said Qaddour.

Some remedies for attacks are straightforward. Reverse ventilation systems, which pump out toxic gas in the case of a chemical attack, can keep underground and cave hospitals safe, but these systems are expensive.

Syrian hospitals illustrate how drastic cuts to foreign aid could backfire in the long run. Protecting hospitals keeps more Syrians in their cities and homes, and out of refugee camps. And, as U.S. military and government officials have long recognized, foreign assistance is an important tool in the fight against terrorism. If aid is cut off, that creates a space that allows other, less desirable groups to provide assistance, thus earning the gratitude and loyalty of the Syrian populace.

“If we’re not able to fund these humanitarian projects that we have been funding for five or six years now, who is going to fill those gaps?” said Qaddour. “There are entities that could fill that gap – when good guys leave a vacuum, the bad guys are pushed to fill it.”

Hariri, the surgeon from Aleppo, is currently completing a one-year fellowship at the Harvard Humanitarian Initiative, but hopes to return to Syria soon. He knows that the long-term solution to the struggles of the Syrian people can only be achieved by lasting peace. But in the meantime, if ceasefires and safe zones aren’t working, the next best step is to protect hospitals and doctors and those they treat.

“Behind each individual person who is killed, there is a story of a family, of a father, of a mother, and kids,” Hariri said. “In reality, it’s not about numbers. People are not numbers.”

This piece has been updated to reflect the precise number of medical workers and facilities that SAMS supports in Syria.

Correction, June 7, 2017: 454 strikes have targeted 310 medical facilities in Syria since 2011. A previous version of this article stated incorrectly that 454 medical facilities had been targeted.


Bethany Allen-Ebrahimian is a journalist covering China from Washington. She was previously an assistant editor and contributing reporter at Foreign Policy. Twitter: @BethanyAllenEbr

Tag: Syria

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