Documenting the "Burden of War" on Syrians

Half of the population of Syria is either outside the country or is displaced. Weatherhead Center Faculty Associate Jennifer Leaning is co-directing a new Lancet Commission to investigate the public health consequences of this epic war.

Image of Syrian Kurdish refugees traveling

The war in Syria is remarkable in its cumulative destruction of a society in a short six years. The toll on human life has been heavy; the involvement of multiple states, factions, and terrorist groups undermines resolution; the instigation of forced migration unprecedented; and the unfettered aerial bombardments against civilians—and perhaps most viciously, the deliberate destruction and targeting of health care facilities, health care workers, and patients—have defied all norms of war.

Achieving an accurate picture of the human cost of this conflict has been an extraordinary challenge for aid agencies and health officials. In an effort to understand the impact of the war thus far, last winter the British medical journal the Lancet convened a commission of medical professionals to investigate and report on this conflict through the lens of public health. In Lancet parlance, a commission is always anchored at an elite university; in this case the American University of Beirut (AUB). In an early publication to set the stage, The Lancet-AUB Commission on Syria (the Commission) has called Syria “the most dangerous place on earth for health care providers,” and notes that the many reported atrocities “undermine the principles and practice of medical neutrality in armed conflict.”

One of the three co-chairs leading the Commission is Weatherhead Center Faculty Associate Jennifer Leaning, François-Xavier Bagnoud Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health, who has studied war and its long-term effects on societies in many parts of the world, including in the Middle East. Her fellow Commission co-chairs are Professor Iman Nuwayhid, Dean of the Faculty of Health Sciences at AUB, and Dr. Samer Jabbour, a cardiologist on the AUB faculty. The Weatherhead Center sat down with Jennifer Leaning to discuss the Commission’s work, its goals, and the scope of the devastation in Syria.

Image of Jennifer Leaning and two colleagues

Q: Why is this particular commission unique for the Lancet?
 

A: A Lancet Commission is a separate publication of the Lancet and is oriented toward big problems in health. This is the first time it has decided to do something on war, in any dimension. The particularities of the war in Syria are very pressing, so it makes sense to ask a group of scholars and practitioners to reflect on the conflict and its impact. All of us on the Commission have decided to produce a blockbuster publication about the ways in which war is a credible topic for public health inquiry. You might think that's odd. But public health as a discipline, or as a set of disciplines, has only very recently begun to take war seriously. The public health community in general has been very much oriented toward the study of illness and health in stable societies. This perspective arises at least in part because the key approaches of public health, in terms of epidemiology and health policy, are best applied towards populations that stay in one place and towards institutions that work. It's hard to do epidemiology of unstable populations, just by the nature of sampling methodologies and issues of access to people. Health policy crumbles into dust when you're dealing with the narrow malignant focus of governments at war.

Q: At the highest level, what is the nature of the Lancet team’s work?
 

A: We are looking at what I have coined the “burden of war” on civilian populations. We are unpacking the notion of “burden” to put all the factors and variables together—loss of life, obliteration of homes and infrastructure, destruction of habitat, assaults on culture and memory, and stunting of prewar possibilities. We will attempt to show this fractured picture to the public health community and say, if this is not a public health problem, what is? In this process of excavation and exploration, we will aim to stimulate and perhaps require the public health community to take war seriously and study it more, with much more expertise developed around means and methods. We're working with public health officials, doctors, and scholars who want to assemble all of the facts before they cohere around a recommended policy approach. Obviously, this war is wrong. This war is horrible to human beings and devastating to the established political and social structures of the Middle East.

Q: What will be some of the Commission’s outputs, if you will?
 

A: We are going to speak out about the destruction within Syria, injury to life, and to the environment. There are many tethers to memory that make your home what it is. Many of these are getting wiped out. We're working with people who have assembled a remarkable database about cultural destruction using satellite imagery, and we're going to try to layer it over time and space with datasets we have about destruction of health facilities, injuries, and deaths. We will get a timeline of the war, to know when incidents happened and what kinds of disruptions took place. A number of datasets have been compiled by people who were energized by this war but have not been able to do much to stop the fighting. So there's a lot of sophisticated documentation. The Commission is also now in the process of trying to gather information from many different sources about many topics—not solely the situation in Syria, but also the larger social and political context, the international humanitarian and security response, grave violations of the laws of war, refugees in the region and in Europe, and other related topics. We had a really productive collaboration at our recent meeting in Beirut. There is a planned series of meetings this summer and into the fall, and then we will be submitting a final report to the Lancet in January. The anticipated publication date will be in May 2018.

Jennifer Leaning quotation on health policy

Q: Will the Commission’s report take a position?
 

A: In terms of policy impact, we're going to be speaking about the high urgency of establishing early warning systems for alert and early action to intervene much earlier in unfolding political and military crises that threaten human populations. We will also be addressing the blatant and significant response failures in the international humanitarian and security architectures, established after World War II. We will show that people should have known. And that they should have intervened earlier. This is a war that should not have been allowed to explode and consume a civilization.

Q: Which parties are deliberately targeting civilians in this internationalized civil war?
 

A: All parties to the conflict insist that they try to avoid civilian casualties. Yet certain war strategies and tactics—such as involving aerial bombardment of cities and towns, employing indiscriminate artillery shelling in densely populated urban areas, using chemical weapons in the face of explicit prohibitions in international law, and relying on siege and forced displacement and/or entrapment of civilians—these strategies are used by some parties in the conflict more than others. We will be documenting the impacts and identifying the responsible parties.

There are practical and moral reasons why these strategies and tactics have been discouraged or prohibited under international law. Without restraint of norms, civilian casualties increase dramatically and those who would help are killed or have to flee. There have been loose estimates of about 500,000 deaths and there remain an unknown number of injured, which is a sign in itself of how little people understand what's going on and how difficult it is to treat people—let alone collect information—in these deadly circumstances.

Image of Security Council Resolution

Q: What do you think are the underlying reasons why the international community has failed to intervene?
 

A: People are outraged about this war in part because there has been a failure of the humanitarian community and also the international security community (established since World War II) to intervene, stop, or mitigate this unfettered use of weapons against civilian populations. Among the most problematic is the belief that terrorists “lurk” within the civilian populations. I don't mean to say that they don't. But the term “lurking” permits an ominous undercurrent that promotes the (illogical) implication that all civilians are terrorists until proven otherwise. Since precision on this point appears impossible, the international community and many governments (including the United States) can justify their hesitancy about moving definitively into this environment. The tremendous irony in this professed uncertainty is that by not engaging in vigorous protection, many civilians are getting killed or are dying each day.

This clouding of distinction, along with the very heavy political challenge in the UN Security Council to reach consensus on collective action, impedes the construction of a strategy that would permit international security initiatives, whether sanctions, blockades, or insistence on insertion of UN peacekeeping forces. Leadership in the United States is degraded by domestic concerns and the drag of two major ongoing conflicts in the region, Iraq and Afghanistan.

Related to the political constraints are the exhaustion and overextension of the humanitarian enterprise. Amidst the many punishing armed conflicts and major disasters that describe our everyday world, appeals for funds to support Syrian refugees in the region are unmet or only very partially so, and organizations cannot find sufficient human resources to address the needs. And then, as we all know, a growing Western xenophobia has been building just as the knocks on the door are becoming more numerous and more desperate.

Image of Domiz refugee camp

Q: Critics fault Obama for not using military intervention when Assad obviously crossed the proverbial “red line” in 2014. Is there any validity to the argument that it could have been a turning point in the Syrian conflict had the United States acted?
 

A: Everything became much more difficult when the Russians entered the war in 2015. And one of the critiques raised by many is that in 2014, with the United States’s refusal to cross that established red line, when proof was officially provided of Assad’s documented use of chemical weapons against civilian populations, the United States lost standing in the Middle East and in the international community. Many analysts suggest that the Russian entry is directly the result of the Americans failure to act a year earlier.

We ceased to be a player in the force fields of public opinion after that point. Although the United States deployed special forces or advisors to the conflict zone, and then later committed more significant military resources, the perception of US indifference has endured. Once the Russians swiftly established a major foothold in the country, the Syrian civil war became an indirect conflict between two major nuclear powers. That reality will always deflate (as it should) US interest in getting deeply involved in major military confrontations. So now we have this game of dynamic checkers in the sky—who's in that space so we won't go into it?

There are still ways in which the great powers can move and the others will get out of their way. However, the United States didn’t move. So, if there is a sense of bitterness at all in the Middle East toward the great powers it's toward the UN, yes, but it's particularly toward the United States.

Q: With the Syrian Civil War, we are reminded of the Balkans War, and the protracted battle between the Serbs, Bosnians, and Croatians. Ethnic cleansing was rampant. But when the atrocities in Srebrenica came to light, the international community stepped up. Why is this not happening in Syria, even though the world has witnessed the recent Sarin gas attack?
 

A: During the 1990s, it was possible to work with the Russians on a number of different fronts. And if it had not been for the Russians basically telling Milošević to stand down, that war in Kosovo would not have come to a rapid end. So in a different alignment of the great powers, it was possible to think and act differently then. We're in a bad time now.

Many of the senior policy people in the UN belatedly learned an important lesson in Yugoslavia. They watched Milošević goading some of his lackeys to do horrible things. There was this sense of “Oh my god, we're looking at ethnic cleansing every day. Why aren't we doing something?” Despite this daily recognition, it took an enormous amount of tragedy and bloodshed punctuated by dramatic instances of horror, and most specifically the massacres of Srebrenica, before the UN and NATO finally realized that they had to send in an aggressive air bombardment and active fighting troops to bring the conflict to an end. So that was in the summer of 1995, and by the fall of 1995 you had the Dayton Accords. With tiny Kosovo in 1998–1999, with Milošević again the aggressor, President Clinton said, this is a threat to international peace and security, what's going on? The NATO bombing after the breakdown of talks in many ways drove the Serbs and their paramilitaries out of the country. This Kosovo action blew through established protocol and perhaps strict readings of international law. But from a political standpoint, and I would submit a life-saving standpoint, it is good that we had the effrontery and the acknowledged capacity to have done that. And it is also very good that the Russians stayed their hand. But Syria is vastly more extensive and complicated than Kosovo.

Q: In retrospect, what kind of intervention could have taken place in Syria?
 

A: Syria has been known as a troubled, autocratic state with divisions between and among the population tightly controlled by the Baathist government of Bashar al Assad. So the context of chronic discord should have kept Syria on the international watch list. And even before 2011 it was clear to informed observers of Syria that there might be major distress migration from drought-affected northeastern regions of the country into the cities of the south and the west. The drought began in 2006 and caused the collapse of livelihoods; livestock died, crops failed. People decided to move out of necessity. Over a million rural Sunnis from this northeastern region—who are relatively poor, relatively uneducated—moved into the more prosperous Alawite cities. Sectarian and class issues, aggravated by vast overcrowding and stress on urban houses, schools, and jobs, underpinned the next chapters of discontent, protests, and ultimately complex civil war.

So, had early warning been in place, the sight of people moving into the cities in 2010 and early 2011 would have triggered an international alert about this forced migration and recognition that it spelled trouble.

We will explore some of the pivot points around this descent into war in the report. In a counterfactual long shot, out of context, it seems hazardous to raise choices leading to alternative realities. But there are a few flare points that we're going to identify in our report, where, if there had been intervention of certain kinds, might have made a difference.

Image of Syrian refugee walking in downtown Homs, Syria

Q: Assuming the ideal outcome, when the fighting stops, what will be left behind from a public health standpoint? What is the likely future of Syria? Can it ever recover?
 

A: We've actually eviscerated the country of Syria. And by “we” I mean the international community, in its failures to intercede, in its failures to respond with abundant strategic measures. Half of the population is either outside the country or is displaced, and this includes the approximately 6.5 million who are internally displaced. Syria as a country is going to be very hard to reconstruct as a political entity. The details of future ceasefires and governance are best known to people involved at all levels in the various negotiations now underway. But looking at it from a public health perspective, the country is not going to be easily sewn together. Part of what's going to make it hard to reconstruct is that there has been such extensive destruction of human lives, families, livelihoods, housing, important civilian institutions like schools and hospitals, and cultural icons and major shrines of memory and continuity.

Immediately after the ceasefire period, there will be relief and possibly euphoria. People who have hunkered down and those who have fought can find reserves of resilience. But there are generational impacts on what we're calling human security, or the well-being of human beings, which we think is a proper realm within the field of public health. It’s not just mortality or short-term morbidity that figures into “recovering from war.” We must consider longer-term morbidity, and the building again of community, and shoring up again a sense of hope. These attributes of well-being will vary in substance and detail from country to country. But a particular barrier in Syria will be the continual presence of war survivors. Many people now have survived partly because of the medical and health effort that has been mounted from within Syria. Physicians and health workers report many amputations, many disfiguring and disabling burns. They see the toll taken by penetrating high-velocity bullets resulting in serious paralytic injuries and/or chronic abdominal abscesses, and the consequences of nonmortal brain trauma. And there are many, many orphans and widows. These populations will linger for years and serve as visible markers.

Seeing somebody with an amputation from now until he or she dies is going to evoke the memories of the war, and who was on what side. Grievances are instilled and reinstilled. These human scars, as well as those across the landscape, will impair a return to the normal. You never get back to normal after any war, but especially after these wars waged against civilians, and against international law.

Michelle Nicholasen, Communications Specialist, Weatherhead Center for International Affairs

Weatherhead Center Faculty Associate Jennifer Leaning is the François-Xavier Bagnoud Professor of the Practice of Health and Human Rights at the Harvard T.H. Chan School of Public Health. She is also an associate professor of medicine at Harvard Medical School. She is one of three co-chairs leading the Lancet-AUB Commission on Syria: Health in Conflict, which aims to analyze the conflict through a public health lens and develop recommendations for health needs.

Photo Captions
 

1. Massive Influx of Syrian Kurdish Refugees into Turkey, Syrian men, women, and children flee their homes in 2014 and move northbound, seeking protection by the Turkish government as refugees. Photo credit: EC/ECHO, September 22, 2014.

2. Jennifer Leaning (center) and Iman Nuwayhid, MD MPH, Dean of the Faculty of Health Sciences at the American University of Beirut (left) are two of the three co-chairs of the Lancet Commission on Syria. With them is Fatima Ghaddar, MD MPH, Research Scholar at AUB Faculty of Health Sciences. Photo credit: Used with permission from Jennifer Leaning.

3. Draft Security Council Resolution on Syria Vetoed, The UN Security Council voted a draft resolution related to the suspected chemical attack on April 4, 2017 in the Syrian province of Idlib. The vote was ten in favor of the draft text, two against (Bolivia, Russian Federation) with three abstentions (China, Ethiopia, Kazakhstan). The draft resolution was not adopted due to the vote against by the Russian Federation, a permanent member of the Council. Photo credit: UN Photo/Rick Bajornas, #719924, United Nations, New York, April 12, 2017.

4. Where is Domiz?—A Glimpse at the Impact of the Syrian Crisis in Iraq, In this 2013 photo of Domiz camp, Iraq, refugees have only an average of only twenty-two square meters per person, compared to the forty square meter humanitarian standard. Originally designed to host 15,000 people, today Domiz has over 32,000 registered Syrian refugees. Photo credit: Flickr, ECHO, M. Chatziantoniou, April 22, 2013.

5. Return to Homs, A Syrian refugee walks among severely damaged buildings in downtown Homs, Syria. Photo credit: Flickr, Xinhua/Pan Chaoyue, June 3, 2014.

See also: Conflict, July 2017