Beginning from the start of the Syrian Civil War in 2011, the Syrian government weaponized the lack of access to healthcare as a tool to suppress members of the opposition. As protests against the Syrian government escalated into armed conflict, reports of security forces targeting hospitals and clinics where wounded protesters sought medical treatment emerged. Starting in 2012, systematic weaponization of restricted healthcare access started to occur. The Syrian government passed a law that criminalized the provision of medical care to areas that are held by the opposition without government permission. This effectively restricted access to healthcare for many civilians. Despite condemnation from international organizations, continuous attacks on healthcare facilities progressed. As aggression continued into the pandemic, the world saw how a battered healthcare system severely exacerbated a humanitarian crisis.
The Syrian Civil War began under the undemocratic rule of Bashar al-Assad, where protests started to erupt in Syria in March 2011, calling for democratic reforms and the release of political prisoners. In July of that year, The Free Syrian Army (FSA), composed of defected Syrian Armed Forces personnel and civilians, was formed. The FSA was initially aimed to protect protesters but later became an armed opposition group. In 2012, the conflict escalated into a full-scale civil war as government forces intensified their crackdown on opposing groups. The groups started to unite under the National Coalition for Syrian Revolutionary and Opposition Forces as hostilities continued. In 2013, The Syrian government was accused of using chemical weapons in an attack on civilians in Ghouta. This led to international condemnation and threats of military intervention from Western countries. The use of chemical weapons were extremely effective in causing mass casualties, containing select opposing groups, and straining the healthcare system. Throughout the period of 2011 to 2013, the Syrian government has been preparing to restrain access to healthcare resources and clinics. These preparations, including small-scale attacks on healthcare facilities and field hospitals, undermined and lessened the efficacy of international interventions. The Syrian Civil War is a testament to how healthcare deprivation can be weaponized and to the importance of investing in a resilient health system without the reliance of international resolutions.
In 2013, the Syrian government conducted the first large scale chemical weapon attack that overwhelmed the healthcare system. To increase the potency of the attack, the Syrian government started taking preparatory steps to degrade the healthcare system starting in 2011. The government achieved this by physically targeting healthcare facilities and systemically restricting access to medical care with laws.
In March 2011, the Syrian government began showing their intention of targeting healthcare infrastructures. On March 23rd, an attack on protesters outside a mosque in Daraa, included attacks on field hospitals. Doctors who were treating injured protesters were shot by snipers and medical teams were attacked (BBC, 2011). Signs of a strained healthcare system started to emerge as a hospital in Daraa reported that they have received the bodies of at least 25 protesters who died in the attack (Al Jazeera, 2011). This intention became more apparent throughout the year as targeted restrictions to healthcare access increased. From April to June of 2011, the government started a wave of arrests against medical professionals in the capital of Damascus. The Independent International Commission of Inquiry reported that the attacks on the healthcare infrastructure in Syria is clearly an established pattern. The report continues to write that the “government forces deliberately target medical personnel to gain military advantage by depriving the opposition and those perceived to support them of medical assistance for injuries sustained” (United Nations, 2013).
In October 2011, the government replaced many healthcare workers in hospitals with individuals loyal to the regime, including military personnel, intelligence officers, and pro-government healthcare staff. The country started to experience the growth of government-run hospitals where patients would be tortured and abused in those facilities. Most often, patients were simply refused treatment (Harding, 2011). Many people have reported that they are fearful of properly equipped medical facilities as these were likely run by the Syrian government. Instead, patients chose to go to smaller private hospitals or poorly equipped makeshift hospitals for treatment. Complications arose when private hospitals needed to request supplies from government-controlled facilities. As the war worsened, the demand for blood transfusions for severe injuries increased significantly. However, blood supplies in Syria can only be obtained from the Central Blood Bank, which was overseen by the Defence Ministry. Private doctors have reported hesitancy in requesting blood supplies for protesting patients because of the high chance of such patients being arrested and tortured (Amnesty International, 2011).
In 2012, President Bashar al-Assad issued Counter Terrorism Law 19, a part of which contributed to the statewide criminalization of nondiscriminatory healthcare. Per this law, providing healthcare in opposition-held areas is an act of materially supporting terrorism and is punishable (Amnesty International, 2019). Healthcare workers, who continued to provide healthcare for oppositional forces, faced detainment, overcrowding, poor sanitation, and other forms of direct torture during their arrest.
Under the law, hospitals that treated oppositional forces continued to face threats from the government. In May 2012, a field hospital in Sarmeen was destroyed, with every room burned and every piece of medical equipment ruined. (Human Rights Watch, 2012). This demonstrates that in times of conflict during the civil war, destroyed hospitals were not simply collateral damage but rather deliberate acts to weaken oppositional forces.
In 2013, the weakened healthcare infrastructure in Syria experienced the first major test of its available capabilities. President Bashar al-Assad conducted a chemical attack in the suburbs around Damascus in Eastern Ghouta on August 21st. It is crucial to note that Eastern Ghouta was chosen likely because it has been held by anti-government forces since November 2012. The United Nations investigated the attack and found that it was a well-planned indiscriminate attack that targeted civilian-inhabited areas and was intended to cause mass casualties (United Nations, 2014). Three hospitals in the area reported receiving 3,600 patients with neurotoxic symptoms immediately after the attack. Of those patients, 355 died (Medecins Sans Frontieres, 2013).
Ghouta was not prepared for the attack as it was well planned but discreet in preparation. The attack was the deadliest use of chemical weapons since the Iran–Iraq War in 1988. There were no facilities for civilians to prepare for the attack. It was unexpected to the degree that civilians only knew how to react to the attack as if it were a typical governmental bombardment. Following normal protocols, residents sought shelter in the basement of buildings, which increased net casualties because sarin, the chemical weapon used, sinks into below-ground, poorly ventilated areas (Cairo, 2013).
After the repeated damages that the healthcare infrastructure endured followed by the chemical attack, healthcare facilities across Syria became more than overwhelmed as the standing facilities continued to fail to accommodate a growing number of people in need of care. In Aleppo, the most populous governorate of Syria, only 250 out of the original 6,000 physicians remained by the end of 2013 (Karasapan, 2016). The country was experiencing constant brain drain, where healthcare practitioners leave the country, alongside systemic healthcare deprivation from the government.
The Syrian government continued to use healthcare deprivation as a deliberate war tactic. By 2014, 57 percent of Syria’s public hospitals have been damaged while 37 percent are no longer functioning (Hamada, 2014). By early 2015, more than half of Syria’s medical doctors had left the country (Physicians for Human Rights, 2015). As the Counter Terrorism Law became increasingly strict, the government became responsible for 88 percent of recorded hospital attacks and 97 percent of medical personnel killings. Deliberation is confirmed through the 139 deaths of medical personnel that can be directly attributed to torture or execution (Brown, 2015). Between 2011 and 2016, Syria experienced 346 attacks on 246 separate healthcare facilities (Webster, 2016).
With less access to healthcare facilities, the Syrian population experienced a steep decline in resident well being. The life expectancy of an individual at birth was 74 before the war and dropped to a low of 63 in 2014 (World Bank, 2014). In the same vein, population growth before the war was at 1.7% and has declined to -6.9% by 2014 (World Bank, 2014). Fundamental healthcare services also became increasingly difficult to access since the start of the war. The percentage of toddlers who received measles immunizations decreased from 80% before the war began to 53% in 2015 (World Bank, 2015). Restriction to healthcare has been proven to be an effective war tactic.
Beginning in 2017, the Syrian government began to take militarized actions to regain specific rebel-occupied areas. As a result, the weakened healthcare system in those regions experienced another major step back. On April 4th, the Syrian government conducted another chemical attack on the town of Khan Shaykhun in the Idlib Governorate of Syria (United Nations, 2017). Idlib was particularly targeted because it was widely considered as a successfully governed area by a rebel group since the beginning of the civil war. The attack killed at least 89 civilians and injured more than 541 (Syria Civil Defense, 2017). This attack also overwhelmed healthcare facilities. However, the government had taken direct measures to deliberately restrict victims' access to care. Two days prior to the chemical attack, the largest hospital in the area was bombed (Barnard & Gordon, 2017). To ensure that victims cannot access treatment, airstrikes were also ordered to target a remaining nearby clinic a few hours after the chemical attack (Barnard & Gordon, 2017). By thoroughly conducting attacks and restricting access to tools of survival, the Syrian government deliberately reduced the population in the area, thereby damaging the rebel group’s power and followers.
In the same year, there was another instance where medical facilities were deliberately targeted in actions the government took to regain control of offensive-occupied regions. Eastern Ghouta was attacked once again. On the first day of the military offensive, five health facilities were attacked and either heavily damaged or destroyed. By the end of the offensive, it was reported that 31 attacks had occurred on 26 separate medical facilities (Physicians for Human Rights, 2017).
These two major attacks in rebel-occupied areas further emphasize that in every militarized effort that the Syrian government takes, they also plan to target and deteriorate the healthcare facilities in the area. This action is effective in ensuring that rebel populations face more suffering and higher mortality rates. This is another clear demonstration of weaponizing healthcare inaccess as a tool to combat oppositional groups.
In 2018, the Syrian government took another major course of action to systematically reduce the efficacy of medical care, this time targeting medical supplies. The government constantly disrupted the supply of humanitarian aid, and denied the entry of medical supplies in newly recaptured areas by rebel groups (Syria 2018 Human Rights Report, 2018). Not only were there a lack of facilities to treat patients, this tactic also targets mobile and makeshift facilities that can treat patients who are severely wounded.
From the beginning of the war in 2011 to 2019, there were 566 separate reported attacks on a total of 348 medical facilities in Syria. Approximately 900 medical workers died with 90% of these instances due to the actions of the Syrian government or its allies (Lund, 2019).
With less healthcare facilities and significantly less medical workers, the COVID-19 pandemic in 2020 served as a self sustained attack on oppositional populations. First, Syrians had significant distrust in the government. There was a lack of confidence in the government’s ability to be transparent and people accused the government of concealing the number of cases and deaths from the pandemic (Dadouch, 2020).
In addition, the Syrian government threatened to arrest doctors who tried to tell the truth about the number of patients with COVID-19 and how the hospital capacities have been surpassed egregiously (United Nations, 2020). There were also rumors that the government was killing suspected patients with COVID-19 (Okba, 2020). Because of all of these measures that the government took, there was much distrust between the people and the hospital facilities throughout the pandemic.
Rebel-occupied areas faced additional challenges. For example, the Syrian government had suppressed COVID-19 testing supplies in Daraa. In fact, there are no laboratories that can process COVID-19 tests in the area (Physicians for Human Rights, 2020). Patients in Daraa who wished to access healthcare resources during the pandemic needed to pay and use public transportation to reach functioning facilities outside of the region. This further exacerbated the virus’s transmission in neighboring areas (Physicians for Human Rights, 2020).
It is difficult to conclude how severely the pandemic affected the Syrian population. Not only was there limited census work done by international organizations during the pandemic, the government continued to conceal the number of cases in Syria. Official reports from the government declared that there were less than 7,887 cases of COVID-19 and 345 deaths in 2020. However, international organizations find these figures to be unreliable. It is especially important to note that these figures only reflect the well-being of Syrians living in government-controlled areas (Physicians for Human Rights, 2020).
The government took advantage of the pandemic as a time to regain control of weakened rebel-occupied areas. The government leveraged the weakened state of the population and the healthcare system and consequently escalated conflicts against rebel-occupied regions in Daraa , ultimately regaining control of most of the area (Dar'a, 2020). In addition to the nature of the pandemic, the government continued to withhold humanitarian aid from entering Daraa. By 2021, the Syrian government had regained control of Daraa through forced settlement agreements (Baladi, 2021).
An argument can be made that Daraa would not have succumbed to the forced agreements had it not been because of a weakened population. Many Syrians regard Daraa as the site of the original civil war and the beginnings of the uprising (Tarabay, 2018). Since the beginning of the war, Daraa had been depleted of humanitarian aid and medical resources while residents faced severe impoverishment. Despite the dire situations that Dara has endured, it persevered. The loss of Daraa to government forces demonstrated the victory that the Syrian government created by weaponizing healthcare inaccess during a time of global crisis. It also marked the failure of international intervention.
It is imperative to recognize that throughout the civil war, many international organizations have attempted to make interventions, however, little impact was made. In 2013, the UN Security Council adopted Resolution 2139, demanding an end to attacks against civilians and medical facilities in Syria (Global Centre for the Responsibility to Protect, 2014). However, attacks on healthcare facilities did not falter. Additional actions that the UN Security Council took to enforce the resolution were ineffective as just two years later, Doctors Without Borders reports that there were over 94 attacks on medical facilities in Syria in 2015 alone (Medecins Sans Frontieres, 2021).
Right before the pandemic in 2019, more than half of Syria's public hospitals and healthcare centers were either closed or only partially functioning due to conflict-related damage and shortages of medical personnel and supplies. This resulted in half a million children experiencing chronic malnourishment. Non-communicable diseases and epidemic-prone diseases became the most common causes of illness in Syria. This was further exacerbated due to the pandemic the following year. Rebel-occupied communities had significantly less access to safe water, sanitation and hygiene services compared to government occupied areas (World Health Organization, 2024).
Throughout the Syrian Civil War, it became clear that access to healthcare emerged not only as essential human rights but also as potent political tools used by the government. The pandemic revealed that the deliberate targeting of healthcare infrastructure and the manipulation of access to medical care serve not only to inflict physical harm but also to erode the social fabric, instill fear and mistrust, and assert control over populations. The Syrian Civil War starkly illustrates how the denial of healthcare becomes a weapon of war, shaping not just the physical landscape but also the political dynamics of conflict. It becomes clear that the Syrian healthcare infrastructure must be strengthened and domestic measures must be emboldened as relying on external forces and international intervention is ineffective. Future generations of Syrians must not only recognize the inherent politicization of health but also advocate fiercely for its protection as a fundamental human right.
The global standard for humanitarian conduct in war is defined by the Geneva Conventions from 1949. These standards were signed by every nation on Earth. However, it is important to note that with leadership changes and the outdated nature of many terms, these standards are difficult to enforce. More importantly, under authoritarian regimes such as Syria, domestic standards must be established.
One of the standards installed during 1949 was that civilians should be able to access healthcare in times of war and that it is illegal to attack healthcare workers (Lund, 2019). This standard was clearly not enforced during The Syrian Civil War. One of the ways that this standard can become apparent in future generations is to educate the youth about the importance of humanitarian conduct in war and the need for protection of healthcare in conflict zones. One effective approach is to incorporate these topics into educational curricula at various levels so that it becomes a value that citizens hold. In the most ideal case, it should be such an expectation that regardless of the country’s leadership at a time, people should be able to call out wrongdoing and specifically highlight and condemn humanitarian war crimes. These standards should trump attempts to eliminate nondiscriminatory healthcare such as Counter Terrorism Law 19.
Students should study the weaponization of healthcare in Syria and evaluate international humanitarian war. Nation-specific educational initiatives have been successful in raising awareness and promoting action on similar issues. In countries like Rwanda and Bosnia-Herzegovina, where genocides occurred in recent history, educational programs have been implemented to educate youth about the atrocities that took place and promote reconciliation and peacebuilding efforts (Moshman, 2014; Lanahan 2017). These programs emphasize the underlying mechanisms that exacerbated past conflicts in their respective countries. Syria could do the same with healthcare weaponization.
Another way to protect healthcare workers is to make The Hippocratic Oath universal and widely known, not just within the healthcare system, but also to the public and to government officials. Patients should know their rights and understand that regardless of which beliefs they hold, they have the right to medical care. They should be able to intervene if the oath is breached. The next generation of government officials should also ensure that doctors are not punished for treating certain demographic groups.
The civil war also underscores the importance of investment in resilient healthcare systems. International intervention is ineffective in the form of laws and resolutions, but much rather in helping increase healthcare access equality regionally. This can also be achieved through funding on-ground local organizations that can reach remote areas that are restricted.
Although many healthcare facilities were destroyed throughout the war, limited care was still provided through makeshift hospitals. Organizations such as the Syrian American Medical Society have been instrumental in building these temporary facilities (Syrian American Medical Society). The Syria Civil Defense is another local organization that not only also builds temporary healthcare facilities, but also conducts censusing efforts and search and rescue operations (The White Helmets). These organizations have been especially important during the times where international organizations were restricted access into specific regions in Syria. For example, from 2014 to 2022, Doctors Without Borders was forbidden from entering northwest Syria (Medecins Sans Frontieres, 2023). This demonstrates that international aid can often be more helpful in the form of funding local organizations who are able to get into commonly restricted regions that are often areas that are in the most dire need for humanitarian aid.
In the long term, conflict resistant infrastructure should be built for healthcare facilities. This not only ensures that there will be adequate healthcare supplies during times of conflict, but also reduces severe brain drain from Syria. In addition to increasing the healthcare workforce in the area, residents and soldiers should learn basic but life-saving aid techniques. These teachings should also be infused into educational curricula for younger generations, but also be allocated through local organizations that currently already serve conflict zones.
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