Sameer Al-Doumy/AFP/Getty Images

Men inspecting a hospital damaged by an air strike in a rebel-controlled town, Eastern Ghouta, Syria, May 2017

Article initially published on June 23, 2022 in The New York Review of Books and written by Annie Sparrow


Perilous Medicine: The Struggle to Protect Health Care from the Violence of War

by Leonard Rubenstein

Columbia University Press, 372 pp., $35.00

Necessary Risks: Professional Humanitarianism and Violence Against Aid Workers

by Abby Stoddard

Palgrave Macmillan, 175 pp., $89.99

There is a new medical specialty in Syria. Driven by deliberate attacks on doctors, other medical personnel, aid workers, hospitals, and ambulances, this multidisciplinary field covers mass casualties and severe malnutrition caused by indiscriminate bombardment and blockades of humanitarian aid. Lack of electricity means that operations are often done by the light of an iPhone. Without routine lab tests, pathology services, or imaging beyond X-rays, diagnosis is challenging. Clinical resources—fluids, antibiotics, insulin—are scarce. Without blood banks, transfusions must come directly from donors, often the medical personnel themselves. Triage is redefined as a process of determining not when but whether patients are treated—a calculation of their odds of survival against the use of finite resources. This is siege medicine.

Since the Syrian government’s brutal repression began in 2011, hundreds of physicians have been murdered. Security forces have “disappeared” hundreds more. By 2015, some 15,000 physicians had fled or emigrated. In areas besieged by the government, remaining doctors must practice far outside their original fields. Pediatricians double as emergency physicians, general surgeons do vascular surgery, and dentists handle anesthesia. Under the expedited system of “see one, do one, teach one,” specialists learn from one another, medical residents rapidly develop broad skills, and even students perform amputations. Those who survive the training end up with expertise in war trauma, competence in managing antimicrobial resistance, and familiarity with infectious diseases previously relegated to history books.

In late December 2017 doctors in besieged Eastern Ghouta, a semirural area of 400,000 people ten miles northeast of Damascus, facing mounting child casualties and intolerable life-and-death decisions, issued an urgent appeal to the World Health Organization (WHO). The head of emergencies withheld the letter from the director-general and did not respond. A second letter, to the United Nations secretary-general, also went unanswered. By April 2018 Russian air strikes had destroyed Ghouta’s last hospitals and Syrian troops overran the area, displacing hundreds of thousands, including the surviving doctors.

Systematic attacks on hospitals amplify the harm of war and increase suffering. The effects reverberate widely, spreading terror and driving people to flee. This exemplifies the weaponization of health care—the use of people’s need for health care against them at a moment when that need is particularly acute. This military strategy isn’t limited to Syria—health care has been heavily targeted in conflicts in Ethiopia and Myanmar. Russian forces invading Ukraine are doing it, too.

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