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Explosive violence and the health challenges ahead for Syria

1/11/2019

1 Comment

 
This is the eighth blog post in a series looking at an array of issues in 2019 related to weapons use, the arms trade and security assistance, at times offering recommendations.
Picture
Iain Overton
It is a hard truth that explosive weapons have a devastating impact on health – from the direct blast that can tear limbs and families apart, to the widespread destruction of health infrastructure and all the painful reverberations this has.  And nowhere else is this truism more evident than in war-torn Syria.

There, according to data by Action on Armed Violence (AOAV), not only has the use of explosive weapons caused at least 79,000 direct casualties - of which about 85% (67,000) were civilians - but it has also devastated state and civilian infrastructure, causing immeasurable harm to healthcare. In Syria, direct casualties from such violence is just the beginning.

Today, with half of Syria’s basic infrastructure non-functioning owing to the war, civilians lack access to energy systems, clean water and other basic essentials – all factors that increase the risk of the spread of disease.[1] At the same time, explosive violence has radically reduced the capacity of health facilities across the country;[2] 60% of health-care services in Syria today lie damaged or destroyed.[3] So, whilst the demand for healthcare is greater than ever, access is significantly reduced and civilians are left ‘dying from injuries and illnesses that are easily treatable and preventable.’[4]

Many medical personnel have also been killed in bombardments; 57% of Syrian medical personnel deaths between March 2011 and December 2017 were caused by explosive weapon use.[5] Others have left; by 2018, with thousands of clinicians having fled the violence, just a third of healthcare workers are said to remain in the beleaguered nation.[6] Such an exodus poses a serious problem. Many physicians are unlikely to return; for some it may be unsafe to do so, for others they may have made a new life elsewhere. In a post-conflict environment, where demand is high and resources are few, medical staff may decide that a better quality of life is to be found in the countries they fled to.[7]

The result of this is that access to care is stretched thin. Doctors’ caseloads have more than doubled,[8] while the lack of staff means there are few specialised services, particularly as donor efforts focus on emergency funding for ‘cost effective intervention’.[9]

Blast survivors are amongst the worst impacted by this reality, faced with highly limited rehabilitation services and considerable difficulties reaching care in the first place. In desperate response to this, living with suppurating wounds and mounting ill-health, many patients have been increasingly misusing antibiotics, a considerable problem in the country even prior to the conflict.[10] Evidence suggests this has likely exacerbated antimicrobial resistance in Syria[11] – causing further significant obstacles for the future.

More than 11.3 million people are said to be in need of health assistance within Syria, including 3 million with injuries and disabilities.[12] A large percentage of those injured are likely to be due to explosive weapons. Amongst 25,000 injured Syrian refugees examined by Humanity and Inclusion, 53% had been injured by such weapons.[13]

In some of the worst impacted areas, the rate of injury and disability is disturbingly high. In a survey of injury and disability across Idlib, Aleppo and Raqqa, as many as 50% of responders were said to be living with some form of disability.[14] The main cause of these injuries were airstrikes (54%), followed by other explosions (28%).[15]

​Amputations are common – one doctor commented that Syria will be left with ‘a generation of amputees.’[16] Alongside this, a Humanity and Inclusion report found that, of injured people in Syria, around 8% required an orthopaedic fitting.[17] Furthermore, with the clearance of mines and explosive remnants of war (ERW) predicted to take 50 years, blast injuries are likely to continue to occur long after the conflict ends.[18]

Amputees have life-long healthcare needs: from rehabilitation and tissue management to further associated conditions, such as ectopic bone formations and osteoarthritis. Such conditions are difficult to manage in a developed healthcare system, let alone a post-conflict environment with a severely dilapidated and destroyed healthcare infrastructure.

The ruin of civilian infrastructure in Syria, beyond health infrastructure, will also have long lasting health impacts on the population. Again, with the displacement of skilled construction workers, alongside the sheer level of redevelopment needed, it is likely that such a threat to health will linger for a long time to come. Syria will almost certainly be witness to increased rates of water-borne or similar diseases in the coming years.[19] One study found physical damage to 457 water supply and sanitation infrastructure assets, not including damage to pipe networks.[20]

The mountains of rubble and waste left in the wake of the bombardment has – and will - also provide the perfect habitat for sand flies, leading to severe outbreaks of leishmaniasis; cases there have increased in recent years by a rate of at least 150%.[21] The most common form of leishmaniasis (cutaneous) causes severe skin lesions which can leave scars and inflict serious disability, but there has also been an increase in visceral leishmaniasis, which is often fatal. [22]

The widespread devastation may also herald further health disasters ahead. When explosive weapons destroy buildings, dangerous and toxic substances are often exposed.[23] Little research has been conducted into this harm, and we are only just beginning to understand the consequences. But studies of those exposed to the toxic dust in the collapse of the World Trade Center give stark warnings. By October 2018, over 43,000 people had been diagnosed with a 9/11 related health condition – 10,000 with cancer – and more still are likely to have been affected.[24] This was also in the US, where the medical infrastructure remained intact after the terror attack. In Syria, a lack of safety equipment in clearance operations, a prolonged and widespread exposure due to uncleared waste, and a lack of health infrastructure, only increase the health risks.

Beyond the physical harm, many more Syrians will be left psychologically affected by the bombardment. One Save the Children study found that, among Syrian refugees interviewed, almost all children and 84% of adults reported that bombing and shelling was the number one cause of psychological stress in children.[25]

The outlook for psychiatric care in Syria is dire. With less than 100 psychiatrists across the whole country prior to the crisis and many of those forced to flee, it is certain that most Syrians will be unable to access the psychological support they desperately need.

Overall, the scale of civilian harm and damage to infrastructure has left a health crisis in Syria which is likely to last decades. The lack of infrastructure and staff is unlikely to be quickly remedied, whilst the harm from explosive weapons, both physically and psychologically, will in many cases require lifelong treatment. Such consequences should serve as a warning on the long-term harm from explosive weapons, and states should commit in 2019 to stop using such weapons in populated areas. That is the least that can be done in the name of humanity.

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Iain Overton is Executive Director of Action on Armed Violence

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Footnotes

[1] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.

[2] Cierra Carafice, ‘Where Do We Go From Here? The Story of Syria's Public Health System’, October 09 2017, Middle East Studies Center.

[3] Speech by Peter Maurer, ‘Even wars have limits: Health-care workers and facilities must be protected’, May 03 2016, ICRC. 

[4] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.

[5] Raja Abdulrahim, ‘After the Gas and Bombs: The Health Crisis That’s Killing Syria’, April 17 2018, Wall Street Journal.

[6] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[7] See Dathan, J. ‘When the bombs fall silent: the reverberating effects of explosive weapons’, May 2018, Action on Armed Violence.

[8] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.

[9] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.

[10] Interview with Dr Kinda Alhourani and Dr Tarek Al Mousa, Syrian Expatriate Medical Association, in Gaziantep, Turkey, October 22nd 2018.

[11] Esmita Charani, Senior Lead Pharmacist, Imperial College London, Faculty of Medicine, at the Global Health Forum: The impact of conflict on health care, 19 May 2018.

[12] WHO, ‘Seven years of Syria’s health tragedy’, March 14 2018.

[13] Handicap International, ‘Syria, a mutilated future’, May 2016.

[14] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.

[15] Presentation by Keiko Tamura, Head of Programmes, HIHFAD, Child Protection Sub-Cluster meeting in Gaziantep, Turkey, October 23rd 2018.

[16] Interview with Dr Mohamad Katoub, Advocacy Manager at Syrian American Medical Society, August 7th 2018.

[17] Anne Garella, ‘‘80,000 people in Syria need a prosthesis or an orthosis’’, Humanity and Inclusion, 2015. 

[18] Wilton Park and the Foreign and Commonwealth Office, 2017, ‘Clearance of improvised explosive devices in the Middle East Monday 22 – Wednesday 24 May 2017 | WP1548’.

[19] Interview with Omar Sobeh, Hand in Hand for Syria, WASH cluster coordinator, in Gaziantep, Turkey, October 23rd 2018.

[20] World Bank, 2017, ‘The Toll of War. The economic and social consequences of the conflict in Syria’.

[21] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.

[22] The Lancet, ‘Leishmaniasis unleashed in Syria’, February 2017, Volume 17, pp.144-145.

[23] Andy Garrity, ‘Conflict rubble: a ubiquitous and under-studied toxic remnant of war’, July 10 2014, Conflict and Environment Observatory. 

[24] Erin Durkin, ‘September 11: nearly 10,000 people affected by 'cesspool of cancer'’, September 11 2018, The Guardian.

[25] McDonald, A. 2017. ‘Invisible Wounds: The impact of six years of war on the mental health of Syria’s children’, Save the Children. Available at: 

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1 Comment

In 2019, Latin American Defense Industries Will Strive to Continue Replacing Out-of-Region Imports

1/9/2019

2 Comments

 
This is the seventh blog post in a series looking at an array of issues in 2019 related to weapons use, the arms trade and security assistance, at times offering recommendations.
Picture
W. Alejandro Sanchez
Two important developments occurred in Latin America in the final months of 2018: in late November, Mexico commissioned its new long-range patrol vessel (Patrulla Oceánica de Largo Alcance: POLA) ARM Reformador (POLA-101); while in mid-December, Brazil launched its new submarine, the diesel-electric Riachuelo (S-40). What makes these two ceremonies even more significant is that both platforms were overwhelmingly manufactured domestically.

Out of all Latin American nations, SIPRI’s “Trends in International Arms Transfers, 2017” fact sheet (released in March 2018) only lists Brazil as a major exporter of military equipment; coming in as the world’s 24th largest. While it is not expected that other Latin American countries will be added to that list soon, the region’s defense industries have demonstrated their ambition to learn and apply what they have learned; and they are doing so very quickly for both domestic production and international trade—trends that should continue in coming years. 

Recent National Developments

Latin American shipyards have been particularly busy in the past year. For example, Brazil launched its new submarine, named Riachuelo, and it is constructing three additional Scorpène-class diesel-electronic platforms with French assistance. The PROSUB (Programa de Desenvolvimiento de Submarinos) program is a partnership between Brazil’s Itaguaí Construções Navais and Naval Group (former DCNS), following an agreement between Brasilia and Paris. The infamous nuclear-powered submarine, which Brasilia has attempted to manufacture since the 1970s, remains unclear as construction continues to be delayed.

Meanwhile, Mexico’s state run-shipyard ASTIMAR and Damen Shipyards constructed Reformador, with most of the assembly taking place in ASTIMAR’s facilities. The Reformador is the first of an order of eight POLAs, according to the ASTIMAR-Damen contract, but the future of the program will ultimately be decided by President Andrés Manuel López Obrador, who recently came to power. It is also worth noting that along with Reformador, the offshore patrol vessel ARM Jalisco (PO-167), was also commissioned. The latter is the seventh Oaxaca-class vessel constructed by ASTIMAR, demonstrating that the shipyard can construct a variety of platforms.

As for other nations, Peru commissioned its new landing platform dock, BAP Pisco (AMP-156), in June 2018, and construction is already underway for its sister ship, BAP Paita. The manufacturer of both vessels is the Peruvian state-run shipyard Servicios Industriales de la Marina (SIMA), which is also constructing a variety of riverine vessels for the Peruvian army. Meanwhile, earlier last year the Chilean shipyard ASMAR commenced the construction of a new ice-breaker for the Chilean Navy.

Not only shipyards had a busy 2018. In Argentina, the aircraft manufacturer FAdeA (Fábrica de Aviones Argentinos) has completed the construction and test flights of three IA-63 Pampa III advanced jet trainer aircraft destined for the Argentine Air Force. This is a major development as the Pampa program had stalled for several years. Meanwhile, Brazil’s planemaker Embraer may be purchased by Boeing, which would constitute a major merger; while another Brazilian company, Helibras, a subsidiary of Airbus, continues to deliver H225M helicopters to the Brazilian armed forces.

Trade Within and to Other Regions

Latin American defense industries are not solely constructing platforms for domestic use, they are exporting them as well. Colombia’s COTECMAR signed an agreement with the government of Honduras in late October for the construction of two naval interceptors. This agreement builds upon relations between Bogota and Tegucigalpa as COTECMAR has already delivered a multipurpose support vessel, named Gracias a Dios, to the Honduran navy. Meanwhile, Embraer continues to sell its Tucano aircraft to a variety of clients. Similarly, the Peruvian state-run company SEMAN is actively looking for potential clients for its KT-1P trainer aircraft, which were manufactured in partnership with South Korea’s KAI.

Without a doubt, Latin American governments will continue importing military equipment from extra-regional suppliers as they can provide highly sophisticated hardware. Nevertheless, the point here is that Latin American governments and armed forces want to also produce their own equipment, hence future weapons sales will continue to include “Know How” clauses, so that Latin American defense industries can learn how to manufacture more complex equipment themselves. The close relationship between Mexico and Damen is an example of this type of partnerships as the POLA is based on Damen’s Sigma Frigate 10514 model.

As a final point, the fact that Colombia’s COTECMAR has secured an additional contract to sell interceptor craft to Honduras highlights one important aspect of the ever-evolving arms trade. While extra-regional suppliers certainly offer more sophisticated equipment, countries with limited defense budgets may choose to acquire cheaper but reliable equipment from suppliers that are geographically closer, or with which they enjoy close diplomatic relations.

Analysts that monitor the global arms trade should pay special attention to South-to-South weapons contracts, particularly as certain Latin American defense industries learn how to manufacture more advanced equipment.


Wilder Alejandro Sanchez is an analyst who focuses on geopolitical, military and cyber security issues in the Western Hemisphere. Follow him on Twitter: @W_Alex_Sanchez.

The views expressed in this article are those of the author alone and do not necessarily reflect those of any institutions with which the author is associated.
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Improved Prospects for U.S. Arms Sales Restraint? Look to Congress

1/3/2019

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This is the sixth blog post in a series looking at an array of issues in 2019 related to weapons use, the arms trade and security assistance, at times offering recommendations.
Picture
Jeff Abramson
The odds may at first appear to be against greater restraint in U.S. arms sales in 2019 given a president who loudly touts the supposed economic benefits of weapons sales and refuses to reconsider arms transfers to Saudi Arabia despite (1) the Saudi role in the devastating humanitarian crisis in Yemen and (2) a global outcry over the ghastly embassy assassination of U.S. resident Jamal Khashoggi. But a close examination of Congressional action, much of it building over the last three years, reveals real prospects for limiting the president’s dangerous approach on conventional arms trade.
 
The most high profile signs of this restraint revolve around the most high profile U.S. arms purchaser, Saudi Arabia. A loud rebuke of Trump’s approach to the kingdom came in December when a bipartisan group of 56 Senators took the highly unusual step of using the 1973 War Powers Resolution to direct the president to end U.S. military action in the war in Yemen, including any refueling to the Saudi-led coalition. An earlier vote in March garnered only 44 votes. The outcry over Trump’s unabashed arms support to Saudi Arabia played a large role in changing many Senators’ minds.
 
Another War Powers-based resolution should expect to win Senate approval in the new Congress, when it is re-introduced. In the House, the new Democratic majority would also be likely to approve such a resolution. While leader Nancy Pelosi (D-California) has yet to indicate when a such a measure might be brought forward, she is one of 101 co-sponsors of the previous House version, which was blocked by a late procedural action in December.
 
The War Powers Resolution came on the heels of steps more explicitly addressing the arms trade. In June 2017, 47 Senators voted to block more than $500 million in precision-guided munitions (PGM) sales to Saudi Arabia; and in September 2016, 27 Senators supported stopping a $1 billion tank sale. While neither of these measures were successful, they indicate the building Congressional opposition to unrestricted arms sales to Riyadh. That sentiment was encapsulated after the recent War Powers vote when co-sponsor Chris Murphy (D-Connecticut) said that “momentum is…only growing. Congress has woken up to the reality that the Saudi-led coalition is using U.S. military support to kill thousands of civilians, bomb hospitals, block humanitarian aid, and arm radical militias.”
 
In addition to these very public votes, some Congressional leaders are acting in other ways to reign in unwise arms sales. Under the U.S. system, leaders within the Senate Foreign Relations Committee and House Foreign Affairs Committee are pre-notified of potential arms sales. That pre-notification period has been the more traditional place for an opposition hold on controversial sales. For a period in 2017, former SFRC chair Bob Corker (R-Tennessee) declared a hold on new arms sales to Gulf Cooperation Council countries. More recently, ranking member Robert Menendez (D-New Jersey) placed a hold on PGM sales to Saudi Arabia and the United Arab Emirates. While Corker is no longer in Congress, Menendez retains his position and his June 2018 hold remains in place. During the recent War Powers debate, he argued that the Trump administration view of the U.S.-Saudi relationship was “unhinged” in thinking that “selling weapons to the Saudis was more important than America’s enduring commitment to human rights, democratic values, and international norms.”
 
These actions are promising, and creative Congressional leaders have the opportunity to do more. While the public can be an ally for responsible action on Foreign Military Sales (FMS) because such government-to-government negotiated sales are quickly added to a public website, the increasingly important business-led Direct Commercial Sales (DCS) are not as transparent, in part because any public notification often comes after the initial review period has passed. Congressmembers could insist that, or possibly take it upon themselves to make, these potential DCS transactions public immediately. Saudi PGM sales, for example, have come through the DCS process and relied upon concerned leaders to share in raising awareness.
 
While the notification period garners the most attention, Congress also can block a sale up until weapons are delivered. Given how security, geopolitical, and humanitarian realities can change between the time of notifications and often years-later deliveries, leaders should follow the entire process. To the best of my knowledge, however, the relevant chair and ranking committee members have only once used the power they gave themselves to receive from the State Department a notification of an arms shipment at least 30 days prior to its delivery. It’s time to exercise, and to expand, such authority (see Section 201).
 
In general, transparency around arms deliveries remains too obscure as a New Hampshire NPR reporter recently discovered.  When U.S. Census export data showed weapons worth more than $61 million were sold from his state to Saudi Arabia in August, he could not uncover what was in the sales nor which companies provided the weapons. Annual reports on U.S. arms transfers have grown increasingly opaque. Congress should mandate a change, demanding much greater transparency on the specifics of what is in U.S. weapons deliveries.
 
Finally, sometime in the first quarter of this year, we can expect the administration to publish final rules transferring export authority on select firearms from the State Department to the Commerce Department, despite a large number of negative public comments and great deal of concern. These rules have been at the heart of the 3-D gun printing controversy that energized public debate in the middle of last year. Members of Congress have raised an alarm that they will lose notifications about these sales, and need to be prepared to stop, or counteract, this dangerous export process change. Just as Trump’s broad approach on arms sales does, these changes risk making it easier for weapons to end up in the hands of terrorists, international criminals, and abusive regimes as well as further undermine the promotion of human rights norms that should be central to U.S. actions.
 
Jeff Abramson is a non-resident senior fellow at the Arms Control Association and manages the Forum on the Arms Trade.
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Milestones Ahead on Landmines and Cluster Munitions

1/2/2019

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This is the fifth blog post in a series looking at an array of issues in 2019 related to weapons use, the arms trade and security assistance, at times offering recommendations.
Picture
Hector Guerra
The Mine Ban Treaty (MBT) and the Convention on Cluster Munitions (CCM), cornerstones of humanitarian disarmament, remain robust and meaningful international instruments that save lives, limbs, and livelihoods.

In 2018 there were advances in the universalization and implementation of the CCM. Namibia, Gambia, and Sri Lanka became States Parties. The latter, immediately after joining the Convention declared its interest and availability to preside over it, so following the Nicaraguan Presidency of the 8th Meeting of States Parties, in September 2018, the South Asian country’s candidacy was unanimously supported for it to preside over the 2019 (9th) Meeting of States Parties.

There are now 105 States Parties and 15 Signatories to CCM.

Meanwhile, Croatia, Cuba, Slovenia and Spain completed the destruction of their stockpiled cluster munitions.

At the UN General Assembly’s First Committee, the resolution on the CCM continues receiving important political support, even by states not parties. Also 2018 saw an interesting swing, with Russia changing its vote from “no”, to abstention.

2018 also marked the 10th anniversary of the adoption in Dublin of the CCM—and of its signing in Oslo—, and the 15th anniversary of the Cluster Munition Coalition.

With respect to MBT, the number of its States Parties has risen to 164, that is, about 85 percent of all UN Member States, as Palestine and Sri Lanka joined the Treaty towards the end of December 2017. In both cases, entry into force took place on 1 June 2018.

At the 17th Meeting of States Parties, under the Presidency of Afghanistan, in November, Oman announced the fulfillment of its MBT obligations of destroying its stockpiled antipersonnel landmines. Also, from the MENA region, Mauritania became the 31st country to declare itself mine-free. Meanwhile, Ukraine participated at the 17MSP having belatedly presented its request for an extension of the deadline for the completion of the destruction of stockpiled antipersonnel landmines.

2019 is a special year in the life of the MBT, as it marks the 20th anniversary of entry into force (1 March). Also, the 4th Review Conference of the Treaty will take place, under the Norwegian Presidency, in Oslo. As in the three previous RevCons, an action plan could be expected.

Given existing trends on the use of improvised landmines in conflict areas, one could expect that we will continue having high numbers of victims, at least into the early part of 2019.

Of course, one wonders if among the expectations for 2019, should we not expect more decisive reactions from the international community to increase the very low share (2%) victim assistance receives from the total of international and national support for mine action, abiding by the principles and spirit of humanitarian disarmament. Could 2019 be a year when tougher stances are taken against those states missing their MBT deadlines, or moving from one extension request to the other, with deadlines beyond 2025, the year agreed upon by MBT States Parties under the Maputo Action Plan to complete their respective time-bound obligations according to the Treaty?

With the Second CCM Review Conference around the corner (2020), 2019 could be a year when a series of states, in particular from among the 15 signatories (including Angola, Haiti, Jamaica, Philippines or Cyprus) could take the necessary steps to join the Convention on Cluster Munitions and participate in the 2RevCon as States Parties.

The two RevCons will present an opportunity to define where the treaties are and what is the state of the measures taken to reach a mine- and cluster munition-free world, given the 2025 and 2030 aspirational targets of the Maputo and Dubrovnik Action plans, respectively. The question is: Will we get to the point where no more lives, limbs and livelihoods are lost, in our lifetime, or will that ideal remain a mirage of politically-correct words stated by diplomats in conference rooms?

Hector Guerra is the director of the International Campaign to Ban Landmines-Cluster Munition Coalition (ICBL-CMC)
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