- Authors report the first systematic method for collecting robust data about attacks
- Legal mechanisms must now be developed to use this data to hold perpetrators to account
- Study is part of four-paper Series assessing the evidence base for health interventions in humanitarian crises
The messaging service Whatsapp is being used in Syria to help monitor and collect data on attacks on health care workers and facilities, providing robust data in support of advocacy and accountability efforts.
The system, which enables teams to share data about attacks within 24 hours, identified 402 attacks against health care in Syria between November 2015 and December 2016, according to a new study in The Lancet. The study shows that during this year of the study, nearly half of hospitals in non-government controlled areas were attacked and a third of services were hit more than once.
Attacks on health care have reached unprecedented levels in Syria, now in its 7th year of conflict. Collecting robust and reliable data is important to convince the international community to enforce legal protections, and to achieve accountability for widespread breaches of international law.
While reporting of attacks has improved, until now there has been no standardised method of collecting robust data. Collecting first-hand accounts from people on the ground can result in limited coverage, and using second-hand data such as media reports, satellite images and retrospective accounts can result in incomplete data, and collection is hampered by access constraints, security fears and concerns about confidentiality.
Following the 2010 UN General Assembly Resolution that threats to health care should be addressed, the WHO was tasked to develop a method of collecting more reliable data on attacks on health care.
The new tool was piloted by the Health Cluster in Gaziantep (Turkey), which coordinates humanitarian activities in Syria, including the UN and around 50 NGOs. The Health Cluster supports 352 health facilities in Syria, serving a population of approximately 5.5 million people.
The monitoring tool uses a 293-member WhatsApp group. When an incident occurs, a short message is posted to the group (see Whatsapp message, figure 1). All members with physically-verified information (ie, who have visited the site or were present - not hearsay) are then asked to complete an anonymous and confidential online form to detail location, attack type (eg. aerial bombardment, gunfire, arson), facility type, extent of damage, who was affected, injuries and deaths.
Within 24 hours, the team in Turkey issues a flash update to key partners, the WHO, UN and donors. Every month, data is verified by checking health cluster alerts against external reports. Reports that remain unverified because of insufficient information are also recorded (see map of verified attacks, see figure 3).
From November 2015 to December 2016, 402 individual attacks were identified, of which 158 were verified. A total of 938 people were harmed, a quarter of whom were health workers. Nearly half (44%) of hospitals in non-government controlled areas were attacked and a third of services were hit more than once. Services providing trauma care were attacked more than other services. Aerial bombardment was the main weapon, and land operations to take over a specific location were associated with increased attacks.
Dr Alaa Abou Zeid, Emergency Health Coordinator, WHO Health Cluster, Gaziantep (now Health Cluster Coordinator, WHO, Yemen) and lead author of the paper, says: "On a daily basis, we have witnessed the efforts that partners do to keep health facilities operational, including dividing facilities, such as operating theatres and post-operative care, among locations to try to reduce the risk that all services are affected, or moving entire services underground. Our challenge now is to convince our colleagues on the ground to continue collecting and verifying data, when they have still not seen a reduction in attacks. We urge the international community to mobilise and apply the Geneva Convention with conviction in order to effectively protect health care and similar civilian services in conflict." 
Lancet Series highlights need for improved evidence and reform of humanitarian system
The paper is part of a wider four-paper Series, led by researchers from the London School of Hygiene & Tropical Medicine, UK, assessing the evidence base for health interventions in humanitarian crises. Large-scale humanitarian crises are ongoing in Syria, Afghanistan, Central African Republic, DR Congo, Iraq, Libya, Nigeria, Somalia, South Sudan, and Yemen among others.
Worldwide, an estimated 172 million people are affected by armed conflict, including 59 million people displaced - the highest number since World War 2. In addition to these man-made crises, 175 million people are affected by natural disasters each year.
The four-paper Series reveals significant variations in the quantity and quality of evidence for health interventions in humanitarian crises, and brings together lessons learned from recent failures in humanitarian crises to provide recommendations to improve a broken system.
Professor Francesco Checchi, London School Hygiene & Tropical Medicine, and lead author for the Series, says: "Timely and robust public health information is essential to guide an effective response to crises, whether in armed conflicts or natural disasters. Yet insecurity, insufficient resources and skills for data collection and analysis, and absence of validated methods combine to hamper the quantity and quality of public health information available to humanitarian responders. Far greater investment and collaboration across academic and operational agencies is needed to generate reliable evidence, and improve the response to humanitarian crises." 
Professor Paul Spiegel, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, and Series co-author adds: "The humanitarian system is broken. An unprecedented number of large-scale humanitarian emergencies are taking place, from Syria to South Sudan and Yemen, causing the largest number of people in a generation to be forcibly displaced. The existing humanitarian system was created for a different time and is no longer fit for purpose. Major changes are now needed to put the protection of humanitarian workers front and centre, to align humanitarian interventions with development programmes, to improve leadership and coordination and to make interventions more efficient, effective and sustainable." 
NOTES TO EDITORS
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