Featured Journal Content: Death and suffering in Eastern Ghouta; Mental Health in Syrian Refugee Children

Featured Journal Content

The Lancet
Mar 03, 2018 Volume 391 Number 10123 p813-910
Death and suffering in Eastern Ghouta, Syria: a call for action to protect civilians and health care
Samer Jabbour, Fouad M Fouad, Jennifer Leaning, Donna McKay, Rabie Nasser, Leonard S Rubenstein, Annie Sparrow, Paul Spiegel, Ahmad Tarakji, Ronald Waldman, Rola Hallam, Denis Mukwege, Ghanem Tayara

Since Feb 4, 2018, Syrian forces with Russian support have bombarded Eastern Ghouta, an enclave out of government control near Damascus. This military action has killed hundreds of civilians and injured more than 1550 people as of Feb 21, 2018,1 in an area where about 390 000 people, most of whom are civilians, have lived under siege since October, 2013. The recent escalation is reportedly part of a Syrian Government offensive supported by its Russian and Iranian allies to retake Ghouta. In just 1 day, on Feb 20, 2018, PAX, an international peace movement, documented 110 civilians killed and hundreds injured in 131 air strikes, 44 barrel bombs, 28 surface-to-surface “elephant” missiles, five cluster bombs, and countless other artillery and rocket fire.2 Amnesty International sees this as continuing “war crimes on an epic scale”.3

The Syrian American Medical Society, which has tracked attacks on health-care facilities during the offensive, now reports that 25 hospitals and health centres have been hit, some more than once in 4 days.4 Several health-care facilities are destroyed or put temporarily out of service, reducing capacity by 50% at a time when patients most need care. A doctor in Eastern Ghouta said, “Hospitals are overwhelmed. Floors are overflowing with injured and blood. Those patients we discharged a couple of days ago are now back with more serious injuries…The word ‘catastrophe’ can’t describe what’s happening.”4 The injured are running out of places to go. Retaliatory shelling by rebel groups on Damascus neighbourhoods has also killed and maimed scores of civilians and also deserves condemnation.

Physicians for Human Rights (PHR) found that “the unspeakable suffering…was deliberately planned and meticulously implemented over time”.5 The Syrian Government has not contested PHR’s finding but says it is attacking “terrorists”. This claim is not supported by patterns of attacks,6 which predominantly target civilian areas, and demonstrate a position that all civilians in opposition-held areas are legitimate targets.7

The people of Ghouta endured a deadly sarin chemical attack in August, 2013, in which 1466 people, including 426 children, died.8 This led to the US–Russia sponsored deal to remove the Syrian Government’s chemical weapons stockpile. However, killing and destruction continued by other means. Ghouta has been subjected to regular shelling and artillery strikes, including of hospitals and civilian areas. Compounding the impact of Syrian Government violations of international humanitarian law, many Ghouta civilians suffer violence by authoritarian rebel groups and are impoverished by a war economy in which corrupt Syrian Government and rebel intermediaries participate.9 The worsening situation for civilians under siege and bombardment has long been reported but has not led to an improvement for civilians or even a slight lessening of their suffering.9, 10 The Syrian Government has allowed only minimal and intermittent aid and regularly removes urgently needed medical supplies from the very occasional convoy it permits.9, 10 In December, 2017, Ghouta doctors sent a letter to WHO Director-General Tedros Adhanom Ghebreyesus, pleading for support: “Once, we were family doctors, pediatricians, specialists…now we are specialists in war trauma, chemical attacks and siege-induced starvation.”11 The Syrian American Medical Society estimates that more than 1000 critically ill patients now need medical evacuation. The Syrian Government has allowed only 37 as of Feb 17, 2018. Every day, patients die.

Inaction in the face of unrelenting attacks on civilians represents an epic failure of world leaders.12 The UN Security Council has utterly failed the people of Syria. The UN Secretariat seems to operate without an effective strategy for political negotiations or aid delivery.8, 13 These compounded failures are increasing frustrations with the UN as a legitimate interlocutor on human rights violations everywhere,14 and translate into deaths and suffering. We cannot allow this situation to continue. Political negotiations have not prioritised or reduced attacks against civilians. The Syrian Government’s continued ability to deny aid to populations it is besieging illustrates the failure of the current aid delivery process and the impotence of the UN. There are no mechanisms to ensure timely delivery of aid, delivery of sufficient aid for the entire population, or delivery of the most needed types of aid. From April to December, 2016, PHR documented that only three of the nine convoys to besieged areas in Eastern Ghouta provided aid sufficient for even half of the population living there. Of the remaining six convoys, three provided aid sufficient for less than a third of each area’s besieged population.15 Eastern Ghouta has received aid only once since November, 2017.

In the face of this desperate situation, health professionals and concerned citizens still have something to contribute; we have an obligation to do so, and there is a long history of mobilisation that makes a difference. The three most urgent priorities are to stop the targeting and besieging of civilians, to end attacks on health-care facilities and other civilian targets, and to allow unobstructed flow of aid, including medical supplies and evacuation of the wounded.

Three levels of action are possible. First, citizens and health professionals must press government officials, especially in countries directly involved in the war, to act today. The UN Security Council must end its paralysis, and Russia in particular must not block action to end the siege and attacks on civilians and hospitals. We will closely watch the expected vote on a Ghouta ceasefire at the UN Security Council. But the UN Security Council is not the only forum. Given the UN Security Council deadlock, in 2016, the UN General Assembly took the unusual step of establishing an international mechanism to investigate grave crimes committed in Syria.16 Justice for the unspeakable crimes we are witnessing is imperative for long-term stability in Syria, although it will not bring immediate relief to besieged Ghouta. While this can be a lengthy process, an initial step of imposing sanctions on parties to the crimes would have an impact.

Second, health professionals and concerned citizens must come together and mobilise. We call on health professionals and citizens around the world who are outraged about the situation in Ghouta and international inaction to join hands in advocacy, mobilisation, and public action and call for an end to the violence, attacks on health facilities, personnel, and patients, and for the protection of civilians in Syria.

Third, the UN Secretariat must change tactics and strategy to be more impactful. Protecting civilians, removing siege, and ensuring medical evacuations and flow of aid must be top of the agenda for any UN-mediated negotiation. The UN and its agencies, especially those operating in Damascus, should exert all pressure and use all leverage, including but not limited to flow of funds for aid, to ensure respect for international law and delivery of aid to people who need it the most. The lesson from the 2013 polio outbreak among children in non-government-controlled areas who did not receive vaccines is valuable. Under pressure, WHO and UN agencies used a whole-of-Syria approach to tell the Syrian Government that everyone across the conflict lines must get vaccinated in one programme. 3 million children were vaccinated across Syria, half of them in non-government controlled areas.17 Donor countries can press for reforming WHO–Syria operations to ensure this model extends to all health aid.

Collectively, these actions can contribute to protecting the people in Syria who are suffering so desperately.
We declare no competing interests.


Journal of the American Academy of Child & Adolescent Psychiatry’s (JAACAP)
March 2018 Volume 57, Issue 3
Letter to the Editor
Mental Health in Syrian Refugee Children Resettling in the United States: War Trauma, Migration, and the Role of Parental Stress
Arash Javanbakht, David Rosenberg, Luay Haddad, Cynthia L. Arfken
Syrian children have been exposed to war trauma, limited access to clean water, sanitation, and good nutrition, and for many, stresses of forced migration.1 Despite these exposures by the children and their families, information on the mental health of Syrian refugees is limited. Recent studies have reported the high prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety in adult Syrian refugees resettling in Middle East and the United States (US), where we found a high prevalence of possible depression (32.2%), anxiety (40.3%), and PTSD (47.7%) in adult Syrian refugees soon after arrival (A. Javanbakht et al.)