Medics, Syria and the Geneva Conventions; reports from the (MSF) frontline

MSF clinicians in Syria

Doctors and medics who provide aid in conflict zones are protected by the Geneva Conventions, regardless of which ‘side’ they find themselves on. Recently nine medics – British citizens of Sudanese heritage and who were accompanied by two other medics from Canada and America – travelled to Syria via Turkey, ostensibly to offer medical support. Providing they do not participate in or support combat, or discriminate to whom they offer treatment, they are covered by these Conventions. The UK Government, which appears to have been on a steep learning curve, has made it clear that if and when the nine return to Britain they will not be prosecuted (e.g. under counter-terrorism legislation). The parents of the nine are naturally alarmed, fearing their children have headed for ISIS-controlled territory and so have travelled to Turkey in the hope of finding them and persuading them to return home. Meanwhile, in recent weeks, the mainstream press has gone quiet on the conflict there, even though several million people remain displaced and thousands of civilians are killed each week. But the main international aid organisations continue to operate at the frontline – Medecines Sans Frontieres is one such organisation and, below, we provide three recent, very graphic reports from them on what is happening at ground level in Syria.

A. The context

In recent weeks the conflict zone has seen the Iraqi militias battle ISIS for the city of Tikrit with their sights set next on taking Mosul (another ISIS stronghold); the Kurdish militias attack ISIS from the north, while at the same time maintaining a buffer against any ISIS assault on the Yezedis; the quasi-anarchist YPG and YPJ consolidate parts of northern Syria (particularly Kobani, which they now control, and the Rojava region); and Iranian support for the Kurds generally. However, the Assad forces are losing little ground and continue to exploit the menace of ISIS in order to annihilate vast swathes of the civilian population who oppose the regime and whose only defence appear to be the beleaguered FSA (Free Syrian Army). Meanwhile the Coalition forces continue to offer air and logistical support against ISIS targets wherever they be. In short, when adding into the mix the Sunni-Shia conflicts in Iraq that have never ceased, the region continues to be a mess, both militarily and strategically.

There are some legal considerations:

1. ISIL is not a recognised country by the UN and so the military conflict waged against ISIS and its brutal regime is not strictly defined as war but as a coalition against terrorism. This is why the UK, for example, has not declared war on ISIS but has proscribed ISIS.
2. It is illegal for citizens of Coalition countries to provide combative support to proscribed organisations.
3. It is not illegal to provide humanitarian support in any conflict zone, whether this be medical or other forms of humanitarian support (though, to avoid misunderstandings, this is best done via recognised international bodies, such as MSF, the International Red Cross and Red Crescent).

For an update on what is happening in Syria, click here.

B. The nine medics

Eight of the nine British medics. Clockwise from left: Hisham Mohammed Fadlallah, Tasneem Suleyman Huseyin, Ismail Hamdoun, Nada Sami Kader, Mohamed Osama Badri Mohammed, Rowan Kamal Zine El Abidine, Tamer Ahmed Ebu Sebah and Lena Maumoon Abdulqadir.

A group of nine young British medical students, age 19-25 of Sudanese origin, are feared to have crossed from Turkey into Syria, possibly into ISIS-controlled territory. (An American and a Canadian are also among the group.) The students are believed to have flown to Istanbul from the Sudanese capital Khartoum, where they were enrolled in a medical school, after which they travelled by land to the Syrian border. The students’ families have since travelled to Gaziantep, a city near Turkey’s border with Syria, to locate the nine and to plead for them to return home.

Turkish MP Mehmet Ali Ediboglu believes the students may already be in a ISIS-controlled town close to the Turkish border.  “My assumption is that they have gone to Tel Abyad, because I know that the hospital there is extremely busy,” he told reporters last Sunday. Turkey has been under heavy scrutiny for failing to keep its border with Syria shut to ISIS hopefuls, many of whom are young like the British medical students. In February, three British teenage girls are believed to have entered Syria through Turkey to join the militant group.

C. Report on MSF activities in Syria

(The following reports are adapted from three March 2015 MSF reports.)

Report 1:

After four years, the Syrian war remains as intense as ever and the need for emergency assistance becomes more urgent with each passing day. But the fragmented and shifting front lines, the sheer level of risk, and systematic blockades of international assistance have made it impossible for Doctors Without Borders/Médecins Sans Frontières (MSF) to provide hands-on emergency care in most parts of the country.

Because the needs are massive and still growing, the organization is working with Syrian doctors who have stayed and are determined to operate on wounded people, deliver babies, and provide emergency care to critically ill patients. Over the past three years, MSF has developed a program of large-scale support to underground and improvised health care facilities. MSF supports more than 100 health care structures in government –  and in opposition-controlled zones—all locations where it is not possible for MSF teams to be physically present. The program is increasingly focusing on besieged areas, where little or no international aid reaches the doctors.

The blocking of access and bombardment of areas under siege, such as Ghouta and parts of Homs and Deraa, is causing untold suffering. The military tactic of placing entire communities under siege means doctors struggle to keep any sort of medical activities running and frequently run out of essential drugs and medical supplies.

In northern Homs, for example, approximately 350,000 people have been under siege for more than one year. MSF is supporting eight field hospitals and three medical points in northern Homs. Medical supplies can only reach northern Homs after a perilous journey on dangerous and insecure roads full of checkpoints, where the probability of death, arrest, and confiscation of material is high. Even if it is available, many suppliers do not want to risk selling material like gauze or surgical threads, when they know it is going to be sent into northern Homs. Gauze is considered synonymous with war surgery, and often a supplier is not willing to take the risk of being arrested or shut down for supplying a besieged area. “It is precious, dangerous, incriminating,” said a doctor supported by MSF in Homs. “There are secret outlets supplying us with gauze.”

The field hospitals are providing the full range of services, but do so with severe limitations of equipment and staff. These services are crucial to thousands of civilians because they are trapped with no other options. “We were sending sick children and pregnant women to Homs National Hospital. But many of our patients never came back, so we stopped referring them,” the doctor in Homs said.

Almost all of the field hospitals supported by MSF in Homs and elsewhere in Syria have sustained damage from airstrikes and barrel bombs. “We work underground, literally. There are entire hospitals below the earth. The operating theatre is underground, as are the laboratory and the post-operative care room. Above ground we only keep patients who are stable and can be moved quickly to the basement when the shelling restarts,” the doctor in Homs said.

Today, East Ghouta is the most populous besieged area in Syria, with an estimated population of 800,000 to 1,200,000 people. Starved, bombed, and under siege, the population of East Ghouta is paying a shockingly high price. MSF provides 21 health facilities with up to 60 percent of their medicine and consumables. Earlier this year, one of these field hospitals received 128 patients after a crowded market was bombed. The medical team there was able to save 60 of the casualties, but 68 of their patients died and they used almost their entire stock of emergency room drugs and materials in that one day.

A March 5 bombing on and around a primary school in a rural part of Idlib Governorate was a reminder that the violence is reaching all corners of the country. After the bombing, 50 wounded casualties were treated by the three nearest MSF-supported facilities. Such events are happening with terrible regularity, and the health facilities, in rural as well as urban areas, are struggling to maintain even the most basic medical services.

Report 2:

MSF operating room in underground surgery, Homs

In northern Homs, Doctors Without Borders/Médecins Sans Frontières (MSF) supports all of the medical facilities in the area, a total of eight field hospitals and three medical points. In this area some 350,000 people have been living under siege for more than a year. Barrel bombs and clashes on several front lines are the daily reality, and there are severe shortages of water, electricity, and basic food supplies. 

MSF is the only international organization supporting the Syrian medical networks in northern Homs, providing approximately 50 percent of what the facilities need in medicine and consumables. Today, because of the combination of high needs and the lack of regular support available to these facilities, MSF is aiming to scale up its assistance to 80 percent of some of these hospitals’ needs in the coming months.

Doctor A. is the director of a key field hospital in Al Houleh in northern Homs, where about 90,000 people are living under siege. Here, he describes his experiences.

“We called it a massacre in May 2012 when one hundred people, most of them children and women, were killed in a single afternoon. That was a terrible day, but it is only getting worse in Al Houleh. On the news they call it ‘intermittent shelling,’ but it doesn’t stop—we just differentiate between the sound of heavy and light artillery.

We have set up this field hospital from scratch. We provide emergency care and also a range of services including primary health care and surgery. We have only a few beds, and they are always fully occupied. 

In January we counted fifty barrel bombs in one week. The field hospitals in the area struggle to deal with the high numbers of wounded, doing what they can with limited supplies and few medical staff. In the villages everyone knows everyone, but it was still hard to recognize people from their splintered body parts. We had many surgeries, too many amputations.

Report 3: an account from a doctor in Homs:

“When I say that our village is relatively safe it means that we expect regular, but not daily, airstrikes. Last week a school run by volunteers nearby was destroyed when it was hit by shelling. The impact shattered the glass windows in our hospital, and we immediately transferred patients to the basement. We are caught between two active front lines and when other field hospitals are stretched, they send us the wounded. They arrive in normal cars, because no one has enough fuel to run ambulances.

Being under siege is like an endless night—a night that we’ve learned can get darker and darker. We have run out of basic food and medicine supplies so many times, we try very hard to keep a little extra. We are getting more and more organized; as much as possible we try to plan consumption rates of key medical items. There is an organization that covers some limited salaries and running costs like fuels and maintenance. Only MSF provides us with medicine, and whenever possible we try to stockpile. But within the North Homs area, there are zones that are under even more intense siege—like Al Houleh—and there it is impossible to stock anything. The situation is not as improvised as it used to be—four years have passed. This is going to last a while.

Our village is overwhelmed with thousands of displaced people from all over Homs. They ran away from death, but are now under siege. Our small field hospital was set up to treat the wounded, but with time and because of the siege we now see many children, pregnant mothers, and elderly patients. It’s too dangerous to cross the checkpoints to government hospitals, and many of our patients would rather take the chance of the limited treatment available in North Homs than risk the journey. There are lots of gaps: maternal health care is very limited, and there are only two orthopedic and four general surgeons for around 350,000 people. I’m a general surgeon myself and we rotate among the few field hospitals in North Homs, wherever we are needed, working long hours for very little pay.

Many tireless volunteers support the running of the field hospitals. They don’t have degrees, but they have war experience. I would give them all diplomas if I could. It’s impossible for us to get medicine in any official way. Even basic supplies are scarce, so we started making our own handmade gauze. We make very little, but it’s better than nothing. Blood bags and anesthetics are virtually impossible to procure; people risk their lives to carry small amounts. Vaccinations used to be allowed in, but for the last four months even this wasn’t possible.

Flour and yeast are forbidden; the checkpoints allow eight loaves of bread at a time. We use whatever grains are available—it no longer tastes like bread but we eat it. Whatever is available on the market is so expensive, up to four or five times what it used to cost before the war. Even those who had a little money before don’t have much left now. Electricity and clean water are considered luxuries.

All of us here are living under great pressure. I haven’t left this area in more than three years—you can’t imagine how that feels. I have three children, but I don’t see them enough. I’m like a robot, working day and night, and when I can I go home to my family.

The violence has forced so many people to lead entire lives underground; schools, hospitals, [and] homes are all below ground level. Our home is on the second floor and only last Thursday the building was hit by shelling. Fear is dictating our lives, but while I’m alive I choose to live above ground.”

See also http://reachofwar.msf.org/