Like many a movie, For Sama starts with a bang that sets the scene for the explosions that pepper the rest of the film. Unfortunately, this is no Hollywood action blockbuster with jaw-dropping special effects. The explosions are not pyrotechnics but shelling and barrel bombs falling from helicopters flying overhead. The victims are not anonymous extras but civilians—men, women, and children. With an Oscar nomination and a British Academy Film Award, Waad Al-Kateab's and Edward Watts' 2019 documentary portrays a common life trajectory—finding love, marriage, pregnancy, birth, motherhood—but played out in the tragic context of the siege of Aleppo, Syria, and filmed in large part from within the city's hospitals as they were under attack. The film is a love letter from Waad to her daughter Sama, who was born in a hospital that is constantly attacked, and a passive witness who no longer reacts to the sound of bombs.
The camera rarely flinches in portraying the grim realities of modern conflict. Bloodied children as they come through the emergency department doors, victims of the unrelenting attacks on the city and its people. The boys' faces numbed by shock as they accompany their wounded brother, having been playing innocently in the street. The babies carried by hand from their incubators in the neonatal unit to the basement as the hospital corridors fill with dust, smoke, and debris. The viewer holds their breath during an emergency caesarean section on an injured woman, followed by a profound sigh with the use of chlorine gas on civilians.
And these horrors are exactly the reason why we should watch For Sama. We have become so accustomed to rolling headlines and reports of atrocities around the world that each new incident in a far-off land barely registers any more. The plight of the civilians is what is lost when news coverage focuses on global geopolitical forces and terrorist organisations. As we watch the film, it's impossible to be unmoved by the lives and deaths of these normal people and, with that emotion, an indignation that such inhuman acts are carried out with impunity.
© 2020 Action For Sama
5 years on from the attack on the Médecins Sans Frontières (MSF) Hospital in Kunduz, Afghanistan, on Oct 3, 2015, attacks on health-care facilities are a deliberate and frequent occurrence in many of the world's conflict zones, despite international humanitarian law dictating that they ought to be a red line in the rules of warfare. The weaponisation of health care in Syria has led to more than 600 attacks on medical facilities and the killing of more than 900 health-care workers since the conflict began in 2011. The implications for the health-care community and on the health of the Syrian population are profound; thousands of health-care workers have been driven out of Syria for fear of persecution, for their lives, and those of their families. These illegal and unconscionable attacks continue in Syria and elsewhere, setting a dangerous precedent.
These attacks on health care have both direct and indirect consequences, with multiple immediate and long-term effects. As a result, they have been used as a strategy of the war in Syria, with deliberate and systematic attacks being used to target medical facilities, depriving communities of scarce medical resources and driving them away from areas in which the hospitals are situated. In 2018, the UN Office for the Coordination of Humanitarian Affairs requested that Syrian humanitarian organisations declare the coordinates of their locations; this deconfliction mechanism was intended to make these locations available to Russian, Turkish, and US-led coalition forces with the belief that this would protect them. Although the system was voluntary, humanitarian organisations felt pressure from donors and UN officials to participate, despite prior knowledge that neither the Syrian government nor its Russian allies would respect such an agreement. The failure of the deconfliction mechanism—the declared medical facilities were not protected; rather, they were deliberately attacked—and the limited scope and insufficient findings of the UN Security General-led board of inquiry to investigate the attacks on these facilities has understandably angered Syrian health-care workers and humanitarian organisations, as their staff and patients have continued to be attacked and remain at risk. These failures have reinforced the disregard with which the international community continue to treat those affected by the Syrian conflict.
The no-weapons policy encouraged and respected in most health-care settings is in stark contrast to the scale of the attacks using modern weapons and targeting of ambulances with civilian patients. Direct attacks on medical missions by state and non-state actors are not new or foreign to the humanitarian world, and range from acts of violence by individuals to precision airstrikes destroying hospitals. While the world's gaze is focused on COVID-19, stones are thrown at a paediatric clinic in the Moria refugee camp in Greece, health-care workers globally are at an increased risk of violence during the pandemic, and mothers in an MSF maternity hospital in Kabul, Afghanistan, are systematically shot in their hospital beds, with five women in labour and their babies, two children, and a midwife among the 24 killed.
The same way that a voice reports in the opening moments of the film “Ever since you said the hospital can't be bombed, it's been bombed constantly”, the humanitarian sector continues to speak out and analyse every attack on a health-care worker or a medical facility. WHO, MSF, International Committee of the Red Cross (ICRC), Humanitarian Outcomes, Physicians for Human Rights, and the Safeguarding Health in Conflict coalition are among those especially active in documenting attacks and advocating for political change and enforcement of May 2016's thusfar ineffectual UN Security Council Resolution 2286.
The direct and indirect impacts on children are clear—Save The Children's Stop the War on Children report shows that 420 million children live in conflict zones and, in 2017, more than 25 000 children were directly affected by verified cases of grave violations against children (which include killing, maiming, sexual violence, and attacks on schools and hospitals, among others). For paediatricians, the very fact that a Paediatric Blast Injury Field Manual exists is a sobering reminder of how grave the situation is. The enormity and horror of it can leave one feeling overwhelmed and impotent. As individual health professionals and researchers working with children, we should liaise with our professional medical organisations and use our powerful collective voices to lobby government for enforcement of international humanitarian law. As well as watching For Sama ourselves, we should also ask our democratically elected representatives to do so, and to report on their actions to support the International Network for Explosive Weapons' political declaration to address the humanitarian harm. We should actively support the non-governmental organisations that advocate for effective protection and respect of health-care workers and facilities.
© 2020 Action For Sama
Some groups are taking imaginative approaches to bringing the relevance of the Geneva Conventions to young minds across the world. For example, the ICRC have worked together with the gaming industry to incorporate concepts of international humanitarian law into military video games. Gamers, who are predominantly young men, can engage and interact with a humanitarian group (eg, detecting and clearing mines in the game). Not only does this add a layer of sophistication to the warfare game, it also helps to illustrate how international humanitarian law is applied in the real world.
The need for urgent action has also been felt by the makers of For Sama. Waad set up Action For Sama, a campaign to end the targeting of health-care facilities in Syria, and archived footage is being submitted to the UN International Impartial and Independent Mechanism as evidence of war crimes. The emergency doctor and hospital director of Al-Qudes Hospital (Aleppo, Syria), Hamza Al-Kateab, whose personal and professional presence permeates For Sama, doesn't hesitate when asked about the relevance of attacks on health care to children: “What Waad wants to show in the film is the reality. Hospitals are mainly for civilians—these are not front-line hospitals for wounded soldiers. These [children] are the casualties being received.” The direct impact could not be clearer. “They killed the last paediatrician!” Dr Waseem was the paediatrician present at Sama's birth and was killed while on-call in the hospital attack in April, 2016. CCTV footage in the film shows the eerily calm and mundane activity in the hospital moments before the explosion occured, images that we can all relate to. When Hamza, speaking from London (UK), is asked for suggestions of what health-care professionals can do, he is similarly clear: “We need to show more solidarity to each other and what we're facing…what I felt like when I was in Syria was that no-one cares.”
© 2020 Action For Sama
For Sama Directed by Waad Al-Kateab and Edward Watts 2019 100 min
Acknowledgments
RB is funded by an NIHR Academic Clinical Lectureship (CL-2018-20-001). Funding sources had no role in the writing of the manuscript or the decision to submit it for publication. The views expressed in this article are those of the authors and do not necessarily represent the views of the organisations to which they belong. RB curates film events under the banner of Watch Talk Think and receives no remuneration. The authors declare no other conflicts of interest. We are grateful for discussions with Duncan McLean and Christian Captier from MSF and the Action For Sama team in preparing this article.