Summary
- Since the start of conflict in 2011, 57% of Syria’s public hospitals have been damaged, and 37% are no longer functioning; the Syrian government and its allies have perpetrated 90% of these attacks.
- Women’s health care is sidelined by urgent trauma care, yet prolonged emergencies create issues with family planning, mental health, and children’s health that have lasting impacts on communities.
- International law prohibits targeting of hospitals and health facilities, and new Sustainable Development Goals set targets for improving women’s health care, but international action and assistance to Syria have not lived up to these.
Current Situation
For the vast part due to the systematic destruction of health facilities and murder of health care providers by the Syrian government, less than 25% of women in Syria have access to reproductive services. As a result, women’s healthcare—particularly safe pregnancy and delivery—has suffered greatly: the rate of cesarean sections has almost tripled, accounting for 70% of births in private hospitals, as World Health Organization (WHO) representative Elizabeth Hoff reported, despite high risks for both mother and child that are heightened by the reduced access to continuing care. Preventative care, such as mammograms and pap smears, is all but nonexistent, and women with chronic conditions lack access to medicine and care. Additionally, sexual violence has reached crisis levels, but access to mental health care is minimal, with only one functioning mental hospital in the country and intense stigma surrounding sexual assault and its discussion.
The WHO requested $163 million for its 2017 Humanitarian Response Plan in Syria, allocating more than $60 million to strengthening secondary and obstetric care, but delivering this aid is difficult. In 2014, the UN Security Council unanimously adopted resolution 2139 demanding safe delivery of humanitarian assistance and respect of medical neutrality, but since then the Syrian regime has continued its use of targeted (mortars, missiles, arson) and indiscriminate (barrel and cluster bombs) artillery, expressly condemned in the resolution.
Background
Prior to the outbreak of violence in 2011, Syria’s health care had been steadily improving for four decades. Life expectancy increased from 56 years in 1970 to 73.1 years in 2009, while maternal mortality dropped from 482 out of every 100,000 live births to 52 in the same period. This put the country on track to meet Millennium Development Goals (MDG) of reducing maternal mortality rates by three quarters by 2015, despite difficulty with the second target of achieving universal access to reproductive healthcare. But, since 2011, the Assad regime has routinely targeted health facilities and personnel: in 2012, the Syrian government passed an anti-terrorism law criminalizing medical aid to the opposition, thus justifying the bombing of hospitals and the arrest and execution of doctors. Between 2011 and June 2017, there were 478 attacks on 325 health facilities, killing at least 826 medical personnel. Over 90% of these attacks perpetrated by the Syrian government or allies (with 7% carried out by rebel forces and 3% unknown).
Women living in areas occupied by opposition forces or in actively besieged zones have almost no access to health care at all, and those who do manage to make it to hospitals are at high risk of bombing and shelling. The lack of formal healthcare services has led to an upsurge in the number of clandestine gynecological clinics, but these are often run by “inexperienced and uncertified midwives,” putting newborn children at risk. Even within hospitals, the number of qualified health care providers is extremely limited, with assessments estimating that only 0.3% of health staff were qualified emergency doctors.
The Islamic State, in a propaganda video from 2015, boasted of an “advanced” healthcare system: clean, modern, and fully staffed. However, in reality, Islamic State areas face a personnel shortage as doctors flee or die. Strict gender separation and dress codes on women pose problems during birth or any other neonatal complications, issues compounded by policies like a ban on the importation of Iranian medical products.
Refugees have better access to healthcare than those within Syria, but challenges remain. Rape and sexual harassment are major issues in camps, and over half of all Syrian refugees are in need of psychological services, but only 5% currently receive it. In Lebanon, 41% of young women reported thoughts of suicide and over half of all refugee children are estimated to suffer from PTSD. Women often have to use the same bathroom and shower facilities as men and report being watched while they use the toilet. This leaves women vulnerable to assault, and leads some women to avoid using the bathroom, causing discomfort and frequent urinary tract infections. Births under 18 are rising as contraceptive use falls, though the vast majority of births are in health facilities; reportedly 96.9% of refugee women in Jordan gave birth in health facilities in the first quarter of 2014.
Policy Implications and Challenges
UN Security Council attempts to address the targeting of medical facilities and personnel have met with little success, and 2015 was deemed the deadliest year yet for healthcare in Syria. New development goals—known as the Sustainable Development Goals (SDG)—renewed global commitments to women’s health by 2030, but came without structural changes. US allocation for humanitarian assistance to Syria for 2017 dropped $62 million from 2016 and the defunding of reproductive health programs greatly reduces any possibility additional assistance may be provided for women’s health in Syria in the near future.
In weaponizing access to health care, the Syrian government’s primary purpose is to contribute to siege conditions by denying both civilian and combat populations essential health care. The widespread targeting and destruction of medical facilities is not only a flagrant abuse of international law, but also has profound negative consequences on the civilian population both now and in the future. Reduced access to healthcare, particularly for women, reverberates for years through disrupted family planning and children’s health. Additionally, attacks on health care contribute to the mass exodus from Syria and the resultant destabilization of an entire region. Healthcare must be protected and prioritized, and the international community’s material contributions to health care and implementation of accountability mechanisms for those who target health facilities must match their rhetoric against actions that threaten further damage.