News Release

Attacks on healthcare in Syria are likely undercounted

Peer-Reviewed Publication


Attacks on health facilities and health workers in Syria are likely more common than previously reported, and local data collectors can help researchers more accurately measure the extent and frequency of these attacks, according to a new study published this week in PLOS Medicine.

Violent attacks on hospitals, ambulances, health workers, and patients in conflict areas are grave violations of international humanitarian law and can cripple health systems during the time they are needed most. Documenting these attacks is important to identify strategies to keep patients and healthcare workers safe, influence policy, and promote justice. However, a systematic and consistent method for verifying and quantifying these acts has been lacking.

In this new study, Rohini Haar of the School of Public Health, University of California, Berkeley, USA, Leonard Rubenstein of the Johns Hopkins Bloomberg School of Public Health, Baltimore, USA and colleagues at the Syrian American Medical Society (SAMS) developed a standardized reporting tool available on mobile phones to verify field reports and count attacks on medical providers and facilities. Data collectors used the tool to record basic information on attacks on hospitals, transports, healthcare workers, and patients and report the information to data managers through a secure messaging system. They found more than 200 attacks on healthcare in 2016 in four northern governorates of Syria. In total, 112 health workers and 185 patients were killed in these incidents, and 176 of the attacks were on hospitals and other healthcare facilities. A separate database of healthcare attacks, developed by Physicians for Human Rights (PHR) and based primarily on media reports, counted incidents at health facilities independently. Among 90 facility attacks verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, demonstrating that no one methodology is capturing all the incidents that have occurred.

The authors note that not all data collectors used the mobile phone app, and that complexities of data collection in conflict settings will limit accuracy of the data. Still, they note that this study "... demonstrates the capacity of locally based organizations and data collectors, in collaboration with physicians and other health staff, to contribute to documentation of attacks on health using a mobile systematic data collection application and act as potent agents to report and chronicle this violence."

In an accompanying Perspective, Michael Spagat of the Royal Holloway University of London, discusses the difficulties of conflict research, and stresses the need to continue developing accurate measures of violent acts.


Research Article


The MacArthur Foundation (LR) and the Oak Foundation (LR) generously supported the initial development of the mobile data collection tool and subsidized the initial data collection by the data collectors. Publication was made possible in part by support from the Berkeley Research Impact Initiative (BRII) sponsored by the UC Berkeley Library. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

I have read the journal's policy and the authors of this manuscript have the following competing interests: LR notes another ongoing research project with SAMS. The other authors have declared that no competing interests exist.


Haar RJ, Risko CB, Singh S, Rayes D, Albaik A, Alnajar M, et al. (2018) Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program. PLoS Med 15(4): e1002559.

Author Affiliations:

School of Public Health, University of California, Berkeley, California, United States of America

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America

Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Syrian American Medical Society, Gaziantep, Turkey

Physicians for Human Rights, New York, New York, United States of America

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The author received no specific funding for this work.

Competing Interests:

The author declares that no competing interests exist.


Spagat M (2018) Attacks on medical workers in Syria: Implications for conflict research. PLoS Med 15(4): e1002560.

Author Affiliations:

Department of Economics, Royal Holloway University of London, Egham, Surrey, United Kingdom

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