Attacks against health care in Syria, 2015-16: results from a real-time reporting tool.

Elamein, M., H. Bower, C. Valderrama, D. Zedan, H. Rihawi, K. Almilaji, M. Abdelhafeez, N. Tabbal, N. Almhawish, S. Maes, et al., "Attacks against health care in Syria, 2015-16: results from a real-time reporting tool.", Lancet (London, England), vol. 390, issue 10109, pp. 2278-2286, 2017 Nov 18.


BACKGROUND: Collecting credible data on violence against health services, health workers, and patients in war zones is a massive challenge, but crucial to understanding the extent to which international humanitarian law is being breached. We describe a new system used mainly in areas of Syria with a substantial presence of armed opposition groups since November, 2015, to detect and verify attacks on health-care services and describe their effect.

METHODS: All Turkey health cluster organisations with a physical presence in Syria, either through deployed and locally employed staff, were asked to participate in the Monitoring Violence against Health Care (MVH) alert network. The Turkey hub of the health cluster, a UN-activated humanitarian health coordination body, received alerts from health cluster partners via WhatsApp and an anonymised online data-entry tool. Field staff were asked to seek further information by interviewing victims and other witnesses when possible. The MVH data team triangulated alerts to identify individual events and distributed a preliminary flash update of key information (location, type of service, modality of attack, deaths, and casualties) to partners, WHO, United Nations Office for the Coordination of Humanitarian Affairs, and donors. The team also received and entered alerts from several large non-health cluster organisations (known as external partners, who do their own information-gathering and verification processes before sharing their information). Each incident was then assessed in a stringent process of information-matching. Attacks were deemed to be verified if they were reported by a minimum of one health cluster partner and one external partner, and the majority of the key datapoints matched. Alerts that did not meet this standard were deemed to be unverified. Results were tabulated to describe attack occurrence and impact, disaggregated where possible by age, sex, and location.

FINDINGS: Between early November, 2015, and Dec 31 2016, 938 people were directly harmed in 402 incidents of violence against health care: 677 (72%) were wounded and 261 (28%) were killed. Most of the dead were adult males (68%), but the highest case fatality (39%) was seen in children aged younger than 5 years. 24% of attack victims were health workers. Around 44% of hospitals and 5% of all primary care clinics in mainly areas with a substantial presence of armed opposition groups experienced attacks. Aerial bombardment was the main form of attack. A third of health-care services were hit more than once. Services providing trauma care were attacked more than other services.

INTERPRETATION: The data system used in this study addressed double-counting, reduced the effect of potentially biased self-reports, and produced credible data from anonymous information. The MVH tool could be feasibly deployed in many conflict areas. Reliable data are essential to show how far warring parties have strayed from international law protecting health care in conflict and to effectively harness legal mechanisms to discourage future perpetrators.