In the second sub-category, *Stewardship of resources and work challenges*, participants discussed the challenge of managing and equitably distributing resources, implementing justice, and the priority and triage system. In addition to the service difficulties they faced during the war, which put them in front of dilemmas and conflicts related to implementing the ethical values and principles that they learned, was the issue of remaining neutral. The participants also described a lack of training in disaster ethics, weak ethical policies, and a lack of prior planning that contributed to the difficulty of applying ethical frameworks and codes.

In the third sub-category, *Corruption and organizational pressure*, participants discussed the existence of corruption, favoritism, and negligence leading to difficulties of applying the principles of transparency, fidelity, and honesty with the clients. The participants also indicated that the absence of authority and weak management and monitoring led to implications for the principle of accountability. Furthermore, the participants also described corruption in medical and humanitarian organizations, the lack of coordination and trust between them, and their adoption of different ethical frameworks, which made it challenging to implement them by healthcare workers.

In the fourth sub-category, *Psychological, emotional, and social stress*, participants described mental, emotional, and social tensions they experienced during the war that resulted in physician burnout and incapacitated the moral decision-making capacity of many healthcare workers. The participants also described the absence of international solidarity and support that would have lifted their morale and demonstrated they were not left alone to their fate. Finally, the participants also noted the significant impact of culture and religion on the pattern of decisions and ethical principles adopted by healthcare workers.

#### **Examples illustrating the formation of Category A**

Figures 4 and 5 below illustrate step-by-step how category A was formed, starting from the transcription text and ending with the overarching category. The "meaning unit" (participant's words) includes a quote from the interviews to present the experience or opinion of healthcare workers. The meaning units that deal with similar issues were then coded into a suitable code. Codes containing related issues were organized into subcategories, and subcategories were collected under the umbrella of the main category.

*Figure 4. Example 1 of forming category A*

*Figure 5. Example 2 of forming category A*

**The main category B** (The ethical principles and values used or considered important by participants) **and its codes:**

Since the goal in forming category B was to identify ethical principles and values used or considered important to healthcare workers, there was no need to create subcategories. Figure 6 illustrates an example of how the category B was formed:

*Figure 6. Example of forming category B*

# **5. Category-based analyses and results**

The remaining part of the data (about 90%) was further coded using the new version of categories, and the final textual analysis was completed. The main categories, subcategories, and codes captured various issues. The issues included the challenges and dilemmas healthcare workers faced during the war and their feelings about them, the important moral frameworks and codes used in care, the duties and rights, and the moral values and principles at stake.

# **4.3 Presenting the results**

This section includes a summary of the data extracted from the interviews (e.g., quotes). Figure 7 and Table 8 below illustrate and outline, respectively, the main category A sub-categories and codes:

*Figure 7. The main category A and its sub-categories*

### **4.3.1 Risks from providing care**

### *<IP_ADDRESS> Attacks on medical facilities and threats to healthcare workers*

Participants shared several stories and incidents describing attacks that targeted them and their workplaces, and because these attacks were repetitive, it made their working conditions extremely dangerous and challenging. One participant (M50, DOC), a 50-year-old doctor serving as the director of a medical complex in Syria, shared that since the beginning of the Syrian revolution, he has provided emergency services on the frontlines of the conflict. One of the first difficulties he and his colleagues faced as field doctors was that warplanes targeted medical facilities, such as hospitals, clinics, medical centers, and even ambulances. This direct targeting created a major ethical challenge for paramedics, medical, and humanitarian organizations working on the ground between providing medical and emergency services to the injured and the personal safety of paramedics. M50, DOC stated that he and his team experienced the most difficult of these situations when warplanes targeted them while they transported wounded and sick civilians:

*"In one of the missions, workers in medical organizations went to rescue women and children who were forcibly displaced from the southern countryside of Hama after the Syrian regime and its militias bombed the infrastructure … these were displaced in a desert area … so we headed to an area called Zero Zone, where we were allowed to pass through. At the time, the medical staff … consisted of a doctor, the head of the ambulatory mobile clinic, a nurse, a driver, a pharmacist, and a midwife. When we reached the area, we found 180 women and children. We provided first aid under the heavy bombardment from aircraft machine guns. They were watching us in Zero Zone. When we went out to the hospital in the liberated areas in the north, the warplane targeted us. This warplane started bombing*  *our car … the driver was terrified, and we were afraid. Our work was medical and humanitarian, yet we were bombed in three areas and miraculously survived by God's protection. However, the car was hit by shrapnel. This shrapnel hit the sides of the car and the rear window. Praise be to Allah! We're alive!" (M50, DOC)*

According to the participants, attacks on medical facilities constituted the greatest challenge to the work of medical personnel in Syria:

*"Medical centers were the first target of the bombing. This is without exception for any small medical center, hospital, or private clinic. This was the most worrying and a very frightening issue for all the medical staff since the beginning of the Syrian revolution until now." (M49, DOC)*

The participants expressed their suffering as a result of having to evacuate or change their places several times due to the shelling and destruction of the medical facilities and centers in which they were working:

*"Our center was bombed twice in Syria. More than once, we were forced to evacuate the center … recently the fighting was near the center building and the staff were trapped for three days. Then they managed to escape. The circumstances were dangerous." (M44, DOC)*

*"I worked in about seven to nine hospitals. We had to move from one hospital to another because of the bombing and destruction of the hospitals in which we worked. The bombing turned the hospitals into rubble." (M50, ANE)*

The participants described direct, deliberate, and systematic bombing of their medical centers:

*"I worked in field hospitals close to the battlefronts. So, we were subject to heavy bombardment … Russian and Syrian warplanes regularly target hospitals, health centers, and ambulances. Therefore, we were always at risk. We were bombed directly. It was a direct targeting, not at random. All hospitals were bombed. The attack was systematic." (M46, DOC)*

Even placing a Red Cross or Red Crescent flag over medical centers did not help protect these buildings from bombing:

*"The main problem we suffer is that hospitals are the number one target … we know that in the event of war, they put the flag of the Red Cross or Red Crescent on the roof of the hospital so as not to be bombed by warplanes. In our case, on the contrary, any place with a hospital is considered the primary target of the bombing of warplanes … honestly; this is the main issue that scares us." (M56, DOC)*

In some cases, the targeting was carried out by placing car bombs next to health facilities.

*"A car bomb exploded next to the hospital where I was a director, causing destruction to the hospital. The hospital was in a residential area, so the explosion caused many casualties from civilians and children." (M56, DOC)*

Healthcare workers also reported that they were subjected to chemical bombardment that caused injuries rendering them unable to work:

*"It's a difficult situation, for example, once, warplanes used chlorine in the bombing, and we lost two workers due to chlorine poisoning." (M32, NUR)*

The attacks also affected ambulances and emergency workers, making transportation of the injured and sick to medical centers a problematic and dangerous task:

*"The first difficulty we faced as field doctors working in ambulances in crisis areas was the lack of mercy towards medical facilities … and ambulances. Rather, it was one of the plans of this criminality to bomb medical and educational facilities … on the other hand, we went through many situations where we were on the verge of death.  This is also an important issue concerning the ethics of paramedics." (M50, DOC)*

Targeting medical facilities and the heightened threat to their personal safety increased the psychological pressure among healthcare workers, leading them to experience hard and unforgettable moments:

*"The hospital for which I was directly responsible was bombed. Once, I was watching the warplane, I was a bit far, then the plane bombed the hospital. This was one of the hardest moments you'd see here when a hospital was bombed with its full medical staff in it. You do not know the extent of the damage. Are the medical staff, the visitors … and the patients still alive?" (M39, NUR)*

Participants spoke of continually demanding personal protection for medical and humanitarian workers and the neutralization of their medical centers to protect them from the conflict; still, they reached a stage of frustration as their calls were not heard and were unsuccessful:

*"The main thing that we demanded and did not get is personal safety. You are working as a humanitarian worker. There need to be protection for you and guarantees that you will not be targeted. Unfortunately, this did not happen. On the contrary, for example, two months ago, warplanes and helicopters targeted 20 medical facilities in the Hama countryside. Three days ago, an ambulance was targeted and three paramedics were killed." (M39, NUR)*

Direct and repeated targeting resulted in a loss of a sense of personal safety:

*"You must forget the issue of personal safety. In areas out of the Assad regime's control, there is no personal safety. Since you are basically in a medical facility that is targeted by the bombing. My hospital was bombed twice when we were in the operating room." (M29, DOC)*

In addition to the various attacks on medical centers and facilities, participants described being exposed to direct threats. Among these threats was the danger of passing through military checkpoints and possibly being arrested or killed:

*"Sometimes we had to go through the Assad regime checkpoints, knowing that they might be looking for you. Nonetheless, you ask God to protect you. This was the most horrifying experience." (M44, DOC)*

*"Most of the military checkpoints were notorious, and they pressured us and tried to prevent us from food and drink and everything." (M50, DOC)*

One participant (M27, NUR), a twenty-seven-year-old nurse, worked during his studies and after graduation as an emergency nurse in a field hospital outside the regime's control. He worked in these areas due to the urgent need for medical personnel. While working there, he was arrested by the Syrian regime forces and imprisoned for two years for providing nursing care to the revolutionaries. After his release from prison, he worked in the emergency department again, with the civil defense and with in-field hospitals' intensive care units outside the regime-controlled areas. The participant talked about his experiences during the prison period, his suffering with prisoners, and the diseases they were exposed to:

*"There were strange diseases in prison. The prisoners knew that I was a nurse and that I was arrested in a field hospital … so they turned to me for help despite the grave danger that could result from asking for help … of course, there is nothing to help with in prison. Moreover, there is hardly any life. I mean, the place is not fit to live in, in every sense of the word. For every three prisoners, there are only thirty square centimeters of space to sit. This space is your home and your place. There was a disease that was unknown to me. Some dermatologists who visited the prison diagnosed it, but I forgot what they called it. Six months after entering prison, scales like fish skin appear on the victim's body. Then large cracks occur in the skin. The prisoners repeatedly asked me what to do with the abscess. Sometimes the crack was so wide that the palm of my hand could go into the place of the abscess and between the muscles … once a prisoner bothered me a lot with his questions about how to deal with the abscess, so I told him to ask someone to urinate on it. I could not find any other sterilizer, nor water … I do not think there has been such an abscess throughout the ages … that was about a quarter of the body. I had never seen this before … death is easy and lack of food is easy compared to what we've lived through. I accept everything except this prison." (M27, NUR)*

Another participant (M50, DOC) is a 50-year-old general practitioner who has worked in Syria since 2011. His city was mainly under rebel control, but there were often incursions by Assad regime forces. He primarily works in the emergency department. The participant described that he and his colleagues constantly worry they could be accused of providing their medical services to the rebels. He shared a particularly harrowing experience during the regime forces' first attack on his city where they tried to force him to speak to the media. Here, the participant felt that the regime forces, who demanded that he lie to journalists, were forcing him to do something he did not want to do as a way to achieve the authorities' goals, placing him in a moral challenge between his duty to be honest and his personal safety:

*"When the first attack on the city took place, we were in the hospital, but we preferred to leave … we were afraid that the troops would enter the hospital and kill everyone inside. But they came to me and told me that there were injuries, and they wanted me to examine them … I went with them thinking they wanted to arrest me. But they told me not to be afraid and that I was safe … three brothers were shot dead in the hospital … when the wounded were in the emergency room, a media group came… the military officer asked me to talk to them … but I was very embarrassed. I said, 'what do I say?' He told me, 'say that there were terrorist gangs who hit these wounded people with axes on their heads and killed them' … I told him that I was not authorized to make any statements, neither to the journalist nor to anyone else, and that he should look for a forensic doctor … we never had a forensic doctor. I was very upset, and even if he wanted to bully me, I wouldn't say anything because he wanted me to lie … he looked at me annoyed, wanting to humiliate me, but said, 'well, that's not a problem'. Then he shouted out loud, 'bring someone to stand in front of the journalists and make a video with them while saying what we want'. Here I tried to stay away from them because I was afraid that they would ask the army to arrest me or do something … honestly, I tried to handle the situation wisely so as not to get into trouble." (M50, DOC)*

The threats were confined to healthcare workers and their families, which placed them in complex challenges:

*"Working in Syria was a burden and a huge risk. Your life and your family were always in danger. My wife used to go back and forth between here and Damascus. Therefore, I was afraid for her as she was by my side. Although she had nothing to do directly with what I was doing." (M31, DOC)*

*"Personally, the most difficult thing for me is staying under bombardment and clashes. I was worried about my family. I tried to move them to a safe place, but every new place was worse than before … out of the frying pan, into the fire … having to transport my family to safety was the hardest and worst." (M47, DOC)*

The participants described several accusations from different political or military parties, often due to the healthcare worker treating a patient or injured person those parties considered hostile:

*"They interrogated me and accused me of treating the rebels, not the soldiers of the regime. At that time, it was Ramadan and the atmosphere was very bad. Furthermore, they wanted to arrest me. But I tried to be as wise as possible, and proved to them that that accusation was wrong." (M50, DOC)*

*"We were providing services regardless of affiliation and regardless of differences between military factions. Sometimes we were in difficult situations and were left confused. For*  *example, if we helped an injured person from a certain military faction, we could encounter problems or harm from another military faction. This was one of the issues that bothered us so much." (M32, NUR)*

Kidnapping is yet another threat to healthcare workers in Syria:

*"I used to live in the western countryside of Aleppo, and my workplace was in northern Syria, near the border. There, as you know, kidnapping was very common … I was susceptible to being kidnapped at any moment during my travels. This was dangerous." (F34, NUR)*

The participants also shared personal threats they received when they did not adhere to specific instructions imposed on people in those areas and during the control of some armed groups:

*"During the period when the Islamic State was here, they regularly used to come to the medical center, and always imposed their power. For example, workers who do not grow their beards would be seriously threatened. If we were smoking, too. But despite this, some of them would return to us from the battlefield, and we used to serve them and forget about all those things, including … the way they had treated us." (M32, NUR)*

The frustration and tension of the victims' families (resulting from the lack of treatment possibilities to the war-related horrors they have lived through) prompted them to direct their anger on the health staff members and sometimes threaten them:

*"The main problem that was causing a lot of stress was the repeated attacks on us by the patients' families. You had to accept this because you could not imagine the pain of a father who could not find an antipyretic drug for his son. The issue is that you were not the reason behind the shortage of medicines. But the father would be in an unenviable state. He had to release his anger and found no one in front of him but you." (M29, DOC)*

*"We faced difficult situations with needy people who spoke to us with a harsh tone. But they are needy, and you have to work in the medical and humanitarian field to bear with them." (M39, NUR)*

#### *<IP_ADDRESS> Lack of protection for healthcare facilities*

In this sub-category code, participants expressed profound anger and disappointment that medical facilities were bombed and destroyed despite the United Nations' prior knowledge of their locations. They stated that no firm measures were taken to stop the attacks and protect healthcare workers despite sharing previously-hidden locations of discreet medical centers with the United Nations to spare them from bombing. As a result, these centers were bombed and destroyed with precision:

*"The hospitals that have been targeted lately are the ones whose locations had been given to the United Nations so they wouldn't get bombed. Nonetheless, they have been directly*  *bombed … according to most confirmed sources. Because the targeting of the hospitals was very accurate." (M32, NUR)*

*"Two to three years ago, news leaked to us that the United Nations had given the locations of our hospitals to Russia so as not to bomb them. The opposite happened. You can confirm this by going to the hospitals' websites that have recently been targeted." (M50, ANE)*

One of the participants who worked with the United Nations explained that even he was not safe in his work:

*"Now in my current work, even though I am working for an international organization and the UN but yet we are not on the safe side. Because we are approaching camps in northern Syria which is not 100% safe. And explosions are here and there every second day." (M41, NUR)*

Here, participants expressed confusion and frustration about the lack of protection and the violence against medical facilities that was permitted despite international agreements which the United Nations sponsor:

*"Why are medical centers, hospitals, and infrastructures bombed by a criminal who, in 1949, signed the international law regarding the protection of medical facilities! Yet no one did anything! … Where in the world did this happen! … how does the war start with the bombing of hospitals, clinics, medical systems, and ambulances, which is prohibited by the Geneva laws! … there is an unjust silence on the part of the United Nations and the humanitarian and medical organizations." (M50, DOC)*

#### *<IP_ADDRESS> Balancing duty to care and commitment to humanity with personal risks*

Balancing healthcare workers' duties with personal risks associated with their work was one of the most critical challenges cited by participants. Abandoning patients by leaving their workplaces was a way to secure their personal safety presents a difficult moral dilemma for healthcare workers in Syria. The pivotal question remains: What is the degree of risk that must be considered before deciding to abandon the duty to care?

*"Among the values that were at stake was balancing the safety of the paramedics, in other words, the safety of the doctor. I always used to wonder, while performing my service, whether I was in a safe place or not … once, I was operating, and they told me that the warplanes were all over us! It's a mental struggle between leaving the patient and proceeding with the treatment. You can call it a sacrifice. Among the challenges was having the courage to continue the operation. But in reality, those were unforgettable moments." (M49, DOC)*

*"Frankly, when the bombing starts and an incident happens to you … I am telling you about all the medical workers, there is no morality here and every person follows the principle, 'oh God, I ask you to save me, only me (everyone only cares about himself)'. Moreover, the doctor blames himself, saying, 'why did I put myself in such a situation, and why did I*  *not flee!' The doctor also says, 'blame it not on them, but on me, because I stayed in this place'." (F32, PHA)*

One of the most painful experiences shared by the participants is when healthcare and humanitarian workers must give up the care of the injured and sick due to the dangerous conditions on the ground:

*"The number of people needing care was huge. We often left people unattended either because we had to get out of the area for security reasons and problems or because we ran out of time. Unfortunately, we sometimes had to leave a patient in urgent need of health care. Of course, we are compelled to do this. We must follow the instructions. Because failure to comply with the instructions affects, firstly, getting the security approval to provide the service there, and secondly, this threatens the mission itself … we may then be subject to legal accountability." (M36, NUR)*

*"Sometimes we saw the wounded in front of us, but we couldn't do anything because they were in dangerous places; we couldn't get close to them at all. We were trying, as much as possible, to secure our protection because it is more important than protecting the injured, and we used to work on this basis. Even if the victim were in front of me, I couldn't help him because that would threaten my life." (M25, NUR)*

The decisions of healthcare workers in meeting the challenge of ensuring personal safety under hazardous working conditions were sometimes met with resentment and complaints by patients and their companions:

*"There was a patient who had a direct heart injury … the surgeon opened his chest … he told me, 'look, there are some remains of a heart' … at this time, the alarm went off. We ignored it and started sewing the wound. Then a worker came and told us that we should evacuate … perhaps the warplane got the hospital location and has now returned to bomb it. At that moment, we had just done a simple suturing of the wound because the person was dead. In order not to leave the wound open. Then we headed to the safe zone. At this point, someone seems to have seen us as we were leaving the operating room. He was accompanying the patient. He opened the curtain in the operation room and saw that there was a person on the operating table, no one with him, and blood everywhere. This someone kind of collapsed … I told him that we were not the cause of the other person's death, but that he was already dead, and his heart was torn. We had to leave him like this because a warplane was hovering over us. So that we can survive and be able to help other people. In the end, I felt like he showed me he was convinced, but that, on the inside, he was not." (M29, NUR)*

During exceptional circumstances, healthcare workers would decide to split into two teams, one leaving the medical centers for the field and the other staying to treat patients despite the danger:

*"We had four casualties and, at the same time, there were two warplanes hovering over us. One of them was a helicopter. We received a radar call telling us that our medical center…a*  *target of warplanes. At that time, the warplanes used explosive containers. The explosive container could destroy an entire building … some of the staff were evacuated at our request. We told them to go in an ambulance. We stayed to treat the wounded. Warplanes bombed our medical center, and the bomb was only 50 meters away." (M32, NUR)*

Some participants believed they had to pursue their work despite personal and family risks. Their professional, religious, humanitarian, and moral duties, according to their definition, motivated them to sacrifice:

*"You, as a doctor, should try your best to help. Regardless of the harm done to me or, for example, to my family. I was newly married, and my wife was pregnant.  You sacrifice your soul and risk your family. Your child may become an orphan. However, when you look at the martyr, you do not back down, but rather say that you are no better than he is. This is one of the things … even if you were a doctor … that makes you look fair. You have to value people the way you value yourself, and vice versa." (M31, DOC)*

*"There is an important issue for ethics in this field: a doctor who sees what happens to these unarmed people may sometimes forget himself as a doctor. When he comes to the scene and participates in rescuing dozens of dead children, women, and the elderly, if he has no will, he will retreat due to the bombing. The lives of many doctors, medical staff, and civil defense volunteers have been lost … yes, every organization asks its workers not to put themselves at risk and to adhere to a certain ethical and humanitarian framework … sometimes we risk our lives and die … sometimes we lack the training, qualifications, and the way to protect ourselves from the evil of bombing and killing, but we offer everything that the word "ethics" can mean." (M50, DOC)*

*"Even sometimes, there is a principle that we did not follow: personal safety. They have always taught us that the safety of the first aid worker comes first. However, sometimes we took risks as I told you. We did not leave because of the bombing, or we were advancing to areas that were under bombardment." (M32, NUR)*

*"These wounded … your task is to help them and save their lives after the Lord of the worlds (Allah). You cannot leave. When I came to the hospital I saw military checkpoints on the road, and there was shelling. However, my work starts at this time and I cannot go home or go to the shelter. I have to go to the hospital to help people. I'm a human. If I don't help them, who will! If you wanted to escape from the hospital during the bombing, no one would stay in the hospital. What is the purpose of the hospital then! We opened the hospital and gave our lives … the medical staff, in general, are familiar with this issue and are dedicated. When the injured come, the medical staff don't think about themselves." (M50, ANE)*

One of the participants expressed sadness for leaving his duty to care and Syria. Still, his escape was not because of the bombing but rather the injustice that he experienced as well as the deteriorating moral situation in the country. The participant considered his medical service during the war to be a revolutionary duty and obligation:

*"It is your duty as a human being to help people when the bombing starts, regardless of whether you are a doctor or not. But what if you were a doctor! You can help them and heal their wounds. Even if you can do a simple thing for them. This is complementary to the purpose for which we made a revolution. As it was said, we walked down a path and we had to go through it to the end. We have to perform good deeds to the fullest. However, one of the things that forced me to leave is the injustice between people. You cannot control it. You can stand somewhat against the injustice of the regime and take a position as a human being or as a doctor, and you can help people who have been wronged. But, there is another type of injustice. This other type is represented by the tragic moral situation in the country, and this situation is very tiring." (M31, DOC)*

Many participants connected their work to the importance of humanity. For them, humanity means helping, treating, and standing beside the injured and sick and willing to bear the hardships and dangers of war. However, achieving this human aspect of their duties created ethical dilemmas when trying to maintain the personal safety, which must be primary during the war:

*"If there were an injured person in a house next to you, and, at the same time, there was shooting from the army checkpoint, then you could not send an ambulance to rescue him. Because they would target the ambulance … you would feel here that you are abandoning the principle of humanity, but you cannot sacrifice another human being in order to save a man who may have died. I cannot send paramedics to die too." (M50, DOC)*

Participants also stated that the military forces controlling the ground often do not respect healthcare workers' humanitarian mission and therefore do not accept their obligation to treat injured people from the other side. This created additional difficulties and challenges during their work, resulting in a profound dilemma: Should they listen to the authorities and refrain from treating the victims of the other side, thereby abandoning humanity, or do they continue to treat these people thus risk getting into trouble with the authorities?

*"If a wounded from the other side came to you for treatment … this would be sometimes difficult. You as a doctor have a humanitarian mission to treat any casualty that comes to you.  By gun threat, a doctor must treat someone or not. Sometimes, he has to leave everything and start treating somebody. You must acquiesce to this condition. Otherwise, your center will be closed, and the community will lose your services." (M44, DOC)*

*"The healthcare professionals were always accused without any evidence. They were accused because of their humanitarian intent. Because they are serving other groups. Everyone can point at you that you are supporting other groups and helping injured people. It looks like something bad. It is bad. It was bad as every group banding you from helping other groups.*  *Right! Especially the government. I was accused and I went through investigation also that I am supporting or helping injured people from the opposite side." (M41, NUR)*

*"The second problem for me as a doctor was the pressure we were facing from more than one side to move with them and work according to their wishes. They do not accept that you, as a doctor, have a humanitarian mission. They neither accepted it nor understood it. Almost, the majority were so." (M47, DOC)*

Some healthcare workers preferred to continue working and adhere to their humanitarian duty despite personal risks:

*"Our profession is humanitarian and requires us to be in dangerous places. So we had to. The shelling and danger did not deter us from treating the casualties and wounded. We were doing our duty to the fullest. This was done with the protection of the Lord of the Worlds (Allah)." (M46, DOC)*

#### **4.3.2 Stewardship of resources and work challenges**

#### *<IP_ADDRESS> Lack of resources*

Many participants described a severe shortage of doctors, consultant physicians, specialists, and anesthetists, which disrupted many medical services:

*"For the volunteer doctors, the situation was very good and well recognized by the people … as if they were going to build us statues in our honor … because doctors were like rare coins there." (M49, DOC)*

*"Of course, eye removal requires also consultants, and this is not available in our time of war. That's why you are always arguing with yourself." (M44, DOC)*

*"There were only two female gynecologists and six midwives. That number is too small for 1.5 million people. We had Caesarean sections and gynecological operations in very difficult conditions. On some days, there was no electricity, and on other days, there were massacres at the same time while we were working in the operating room." (M49, DOC)*

*"The anesthetics we had were very few or often not available." (M29, DOC)*

The participants' significant lack of resources included essential medicines, painkillers, intravenous fluids, and vaccines:

*"Some of the needed medicines were not available most of the time. Such as decongestants and antipyretics." (M29, DOC)*

*"In the beginning, resources were scarce and it was difficult to get Declon injection, painkiller, or tramadol because of the blockade and the state of war." (M31, DOC)*

*"I've been working there for five years, and I don't remember IV fluids being replaced at half the normal amount patients really need." (M29, DOC)*

*"During our work, there were basically no vaccines. Our area was besieged." (M29, DOC)*

According to the participants, the lack of necessary medicines during chemical attacks has also complicated the situation:

*"We often do not have the necessary medicines in case of bombardment with toxic substances such as chlorine and phosphorous. We've seen suffocation incidents." (M50, DOC)*

The participants emphasized that the colossal shortage of resources was prominent in the early years of the revolution, especially in areas besieged by the Assad regime which prevented deliveries of medicines and medical supplies:

*"At the beginning of 2013, our city was also bombed … at that time, our equipment was simple. Imagine, I was going to help the wounded, I was carrying a bag of first aid kits, and I couldn't do much." (M31, DOC)*

*"We faced such difficulties, especially at the beginning of the war. There was no support. We had to operate some surgeries without a ventilator. We manually administered oxygen through an Ambu bag (hand-breathing bag). These are primitive tools, and they are insufficient in the case of surgical procedures. Surgery can sometimes be serious and prolonged. But there was no other solution. We had to perform these operations in order to save the lives of the injured, using very scarce tools and capacities." (M46, DOC)*

*"This was a big challenge for us, especially at the beginning of the revolution. Blood transfusion was very disastrous … sometimes we had to transfer blood from a donor to a patient directly. Imagine that we had no blood collection bags and no blood bank labs. We transferred blood from one person to another directly." (M49, DOC)*

Participants described that one of the challenges often faced by healthcare workers is the influx of injuries against the limited availability of equipment and capacities, which presents workers with difficult choices and significant psychological pressures:

*"You often have many wounded and one operating room." (M46, DOC)*

*"Some of the arrivals die there because our initial treatment and management of them were bad because … for example, a patient needs a thoracentesis, and we have no tools to do that." (M47, DOC)*

*"We've come to a point … a state where we're sometimes unable to work and don't know what to do. There were a large number of people flung to the ground because there were no more beds … at the same time, the number of doctors was very, very small. Your experience as a nurse is limited in dealing with these conditions … for example, this person needs a thoracentesis … we have tried to work according to global protocols. But how do you deal with a person who needs thoracentesis while the doctor is busy in the operating room! So I asked myself 'should I do that or not!' Sometimes you are subject to these pressures." (M29, NUR)*

*"These difficult situations were daily because the work was in besieged areas … we had a problem with the scarcity of resources. How to use them and divide them and how to make the decision. We had to make such a decision daily … that was annoying and painful." (M29, DOC)*

*"There were doctors who worked on the triage. But the scarcity of resources costs us a high price. It is one of the causes of psychological pressure on the medical staff. Because the problem could have been solved by using a simple device and a simple procedure. But you don't have this simple procedure, and the resources are not available. There are so many words to say!"  His health is ailing. What can you do to him! There is nothing in your hand. This thing is downright painful and affects us very, very, very, very much. This is too stressful that it was necessary for the worker to get breaks for a few days until he is relaxed a little, and so that he could maintain his psychological and physical health conditions properly." (M36, NUR)*

*"The concern was that you were dealing with a medical condition, in some cases, it could be very complex, and you wouldn't have the initial capacities for treatment. You have to work under such circumstances! This issue had a huge impact on the personal and public levels. You see the person dying in your hands. And you are unable to give him anything." (M27, NUR)*

The participants also described a lack of resources and capabilities for secondary and rehabilitation care:

*"In general, the numbers needed for prosthetics are far greater than our potential. We have a shortage of technicians. Of course, we have a huge project for Syria. But the numbers far outweigh our current coverage." (M30, PRO)*

*"Of course, here in the liberated areas, they focus on two parts, pre-hospital and in-hospital care. They do not care much about the post-hospital and rehabilitation phase." (F34, NUR)*

Decision-making was exceptionally difficult for participants, and when decisions were formed on the basis of distributing scarce resources, those decisions were often painful:

*"The problem was in the decisions resulting from the scarcity of resources. For example, if you had a newborn, you might decide that he would not get an incubator. If he got one, it would consume a lot of fuel because a generator would have to be turned on permanently. That is what we cannot provide. These kinds of decisions were inherent to our scarce resources." (M29, DOC)*

The families of the injured sometimes blamed participants for the lack of resources:

*"There was a shortage of equipment in the emergency room, and that has negatively affected us. For example, when we try to change the bandage for an injured person or try to rescue him, even at the location of the incident, we find that the equipment is incomplete. That thing has negatively affected the injured, his family, and us too. So, the family of the injured person blames us as paramedics." (M25, NUR)*

Participants described having to sometimes purchase medical materials at their own expense:

*"We have a shortage of resources. For example, we sometimes have to pay or donate the money ourselves, so we can buy equipment. This means that simple things were sometimes not available, such as syringes or surgical instruments. The medical staff needs food, and this is also not available." (M50, ANE)*

The lack of resources also prompted participants to invent simple alternative devices or provide experimental care to meet the need:

*"Lack of resources … it was one of the things that got us in trouble. Sometimes healthcare workers were completely helpless. Because the patient or the injured is in front of you and you are unable to deal with him because of the lack of resources. Let me tell you. I once performed chest thoracentesis by a hookah hose … there was no other solution." (M25, NUR)*

*"The scarcity of materials is a major problem. I will give you an example. It was very difficult for intravenous fluids to reach besieged areas, especially to field hospitals. For example, you know, in the abdominal opening surgery, when the surgeon finishes the operation, he flushes the wound with four to five liters of normal saline. We used to replace the standard normal saline with a handmade normal saline. We made it with our own hands … at one point, there was no electricity to operate the sterilizers, so I sterilized surgical instruments by burning. We were using fire. We put alcohol on the equipment and lit a fire for a certain amount of time, so that we could use it again. We used to invent abdominal puncture devices." (M27, NUR)*

*"We sometimes have to do medical adventures and rely on our medical expertise and humanitarian will. We conduct our humanitarian operations until the patient reaches the hospital or emergency center so that we can provide care to him." (M50, DOC)*

The lack of capabilities and resources resulted in participants transferring criticalcondition patients to hospitals in other regions, but the difficulty and severity of movement of patients in this type of condition led to many patients' death:

*"Our capacity was very limited. Sometimes we had to transfer the patient to a distance of 120 to 200 km. Many of the injured, classified as priority, died halfway during the transport." (M47, DOC)*

Lack of resources and capabilities was cited as an obstacle to applying ethical standards and health policies:

*"We have taken many courses. Like the SPHERE program which is known for international standards of humanitarian action. Frankly, the standard has not been fully implemented because your capacities fall short of requirements. Whether it is within the financial capacities as funds, or the capacities in human resources and its availability. Sometimes the resources are not available or are so deficient that you cannot apply the standards you have in mind or for which you have been trained. There is difficulty in the application. This criterion is currently not being fully implemented." (M39, NUR)*

# *<IP_ADDRESS> Working outside one's scope of practice*

According to the participants, a major problem they experienced was the shortage of personnel from specific medical specialties, leading some doctors to perform treatments and surgeries outside their specialty:

*"A child was brought to us at two o'clock at night, and he was only four years old … the child was suffering from a broken thigh and a cut in the artery. There was no vascular surgeon at the hospital. We only had a gynecologist, a surgeon, and a urologist. The orthopedic doctor was forced to perform the surgery and connect the artery so as not to have to amputate the limb and then send the child to another hospital to continue treatment." (M50, ANE)*

Non-clinical volunteers tried to help healthcare workers bridge the specialist gap, but their lack of technical and medical training failed to contribute to the specialist shortage:

*"There was a severe shortage of specialists. Volunteers, of course, may God reward them, have indeed such a big role that they have replaced other missing healthcare workers. But they do not have a scientific background to distinguish between right and wrong or between medical work and nursing work." (M32, NUR)*

# *<IP_ADDRESS> Unqualified persons working in the health field*

Participants recalled unqualified, untrained, or unskilled persons working in the hospitals due to the severe shortage of healthcare workers and medical specialists. This lack of experience and competence negatively affected the participants' and other healthcare workers as well as the quality of health services provided:

*"Some people also worked in the medical field for the purpose of providing assistance … such as working as nurses … but they had nothing to do with the medical field. This had a negative effect later on." (M31, DOC)*

*"If we talk in general, as a health sector, there are a lot of violations. I mean, for example, there are incompetent individuals who have applied for jobs beyond their capabilities. For*  *example, an ordinary person would pretend to be a paramedic. This happened a lot." (M49, DOC)*

*"They only hire those who have nursing experience but do not have a nursing degree from an institute, school, or university. This of course greatly affects the quality of health services." (F34, NUR)*

The participants also described individuals with various non-scientific educational backgrounds, such as humanities or economics, who joined the health sector as nurses after receiving short, possibly days-long training. Financial needs, the lack of job opportunities during the war, and the prospect of being forced to carry arms were motivations for individuals to apply for healthcare roles:

*"There was no full medical team. The medical team consisted mostly of volunteers, not doctors. For example, the nursing teams did not actually consist of nurses but rather of students from other professions … economics, humanities … who have learned quickly, in two days, and then volunteered to work. They also wanted to have a job for a living with some NGO, on an amount of 200, 300, or 400 dollars, as there were no other opportunities, or you must carry weapons and fight." (M49, DOC)*

Participants also reported frequent medical errors by untrained workers, such as volunteers giving medicines and prescribing and dispensing treatments without supervision and qualifications:

*"The medical errors were very frequent. For example, we trained volunteers to work as paramedics. As a paramedic, you are not supposed to deal with drugs and treatment. After a year, for example, the volunteer would tell you that he could do anesthesia, that he knows more than a doctor does, and that he is better than a doctor who stayed with the Assad regime and did not join in here. He would begin to dispense drugs and to give injections." (M32, NUR)*

### *<IP_ADDRESS> Work overload and employment rights*

The lack of resources increased both work pressures and the number of working hours for participants, who described working for long periods of time to compensate for the severe staff shortage:

*"There were times when we had to work seven days in a row. Because no worker from outside the city could come and take our place. The health staff that were in the city became responsible for the whole work. If there were a radiologist in town, a lab worker, or a doctor, they should show up to work. As for the doctors, there were only my colleague and me. There was one radiologist and one technician in the laboratory. The rest of the workers were outside the city and could not come because of the bombing and road closures." (M50, DOC)*

Participants increasingly suffered from these working conditions and were not provided additional financial compensation or alternatives:

*"But what made me struggled there were the working hours. The working hours were very tiring. Sometimes a person had to do the work of two or three doctors at once. Sometimes you had to work for a week or two without additional compensation. Because there is no alternative either. We were often working twice as usual. Our shifts were usually 12 days a month, but we worked 22 or 23 days a month." (M50, DOC)*

Participants also reported the occurrence of medical errors due to the stressful working environment that made it challenging to adhere to standards of care and treatment:

*"A pregnant woman, aged 30 or younger, was brought to us. She needed lumbar anesthesia for cesarean delivery. The anesthesia technician was one of the best workers. He was 60 years old and had more than 30 years of experience. Instead of giving lidocaine, he gave another medicine, and this medication causes numbness in the nervous system … the newborn was born without problems. But the woman was placed on a ventilator and then died. She died because of no other thing … the woman was not at any risk, and she had no previous illnesses. But the cause of death is pressure and stress. When there is too much pressure on the hospital, I will not be able to adhere to the standards that I myself have set. This point should be taken into consideration." (M29, NUR)*

Participants expressed their dissatisfaction with the overwhelming absence of employment rights, which put them into the dilemma of performing duties in exchange for minimum rights or, in some cases, none at all. These rights included health insurance, setting limited working hours, workers' compensation, and appropriate salaries:

*"'Rights!' We did not have rights, but there were duties only." (M47, DOC)*

*"As for rights, there are no rights for organizations and workers in Syria. In Syria, I don't think someone is providing health insurance, social insurance, or end-of- service compensation." (M44, DOC)*

*"As for the salaries, this was also a negative concern for us, and it was not given to us properly." (M25, NUR)*

*"I can mention the issue of salaries. They must give us our rights on time because they are late to give us salaries." (F34, NUR)*

*"Not to delay our salaries and, of course, to provide us with medications before the salaries … working hours should be curbed. These are the rights we need." (F32, PHA)*

Participants also described that, even if they wanted to submit formal complaints or demand better working conditions, their institutions lacked oversight bodies that could compensate and provide them with rights:

*"My rights! I am in these circumstances … there is no longer any control over rights. Things have become a mess. For example, if I want to claim my rights, whom do I turn to! There is no official or civil body." (M50, DOC)*

*"For us, there are no rights. There is no state. We live in a time of revolution. This revolution was subjected to war. We are now being bombed by a superpower … where are the rights! If there is no existing state that gives you your rights! We get the rights here from the Lord of the heavens. We are waiting for God to prepare for us a state, whether in the West or the East, to adopt the rights of the oppressed in the liberated Syrian region." (M50, ANE)*

# *<IP_ADDRESS> The spread of epidemic diseases*

Some participants highlighted that the spread of infectious diseases common to war-times, including hepatitis and diarrhea, occurred in Syria due to the lack of vaccines, blood transfusions without testing, and neglecting the health and personal hygiene of the displaced:

*"The epidemiological diseases usually spread in the time of war, like cholera and hepatitis C, and that is because of the inability to test the blood. The blood transfusion was in chaos, and it happened that such diseases were spread. They draw blood from someone, and, in 3 minutes, they transfer it to the other patient." (M49, DOC)*

*"We detected many cases of TB and fortunately they were non-active cases. So I came across a family where everyone of its members suffers from TB. From the other side, we detected cases of meningitis. It was not a big number. But the biggest problem that accompanies this influx of people is diarrhea. Adults, children, and everyone have diarrhea because the time was in winter and due to hygiene problems. I do not know maybe because of the food they were getting on the way until they arrived. They were traveling in big tracks for three days until they have arrived at the camp. So the situation on the way was not humanitarian at all. They were treated very badly through the forces of you know … they took their money and their things and they did not allow them even to go to pass stool. You see children died on the way due to the cold." (M41, NUR)*

### *<IP_ADDRESS> Expired medicines*

The problem of tainted, compromised, and expired medical aid was described as a significant issue by participants:

*"There is also the problem of expired medicines. There are times when we received a huge aid, but it had already expired. You had to know if that particular substance or medicine was appropriate and consumable. There was great difficulty." (M32, PHA)*

*"Those who send us expired medicines or useless medical instruments from their hospitals!" (M50, DOC)*

### *<IP_ADDRESS> Caring for non-war patients and vulnerable groups*

War conditions forcibly shift attention, priority, and health care away from routine patients to war casualties and critically injured patients. However, the extreme resource scarcity, the lack of planning, or the ill-considered transition from the routine standard of care to the crisis standard of care led to neglect of care for non-war patients and vulnerable groups such as women, children, the elderly, and the chronically ill. That created ethical challenges for healthcare workers and the way they allocate care.

*"I believe frontline healthcare workers are always faced with ethical decisions. Someone might come to you and tell you that he needs a hearing aid device because he cannot hear. But the therapist would reject him and say to him, 'I have patients dying on my table and you want a hearing aid device now!'." (M44, DOC)*

*"The issue of chronic diseases was neglected and less important, although it constituted a burden during that period. Older adults and middle-aged people with diabetes or high blood pressure … suffered the most. Usually, if the patient's diet changes, his condition will deteriorate again. What if he lived in difficult conditions where there is no food or diet! What if the patient had to eat anything available! What if his medicine is no longer available!" (M29, DOC)*

*"The priority was for critical cases (hot cases) and the war casualties. Therefore, health care was directed to emergency cases only. Some diabetics came to us at that time for treatment, but they died later on because no one cared about such diseases, there are no doctors for them, and no medicine … some patients were brought to us with a heart infarction and died in the emergency department even though they were in their 40s." (M49, DOC)*

Footnote: The Syrian women participated in the demonstrations and the revolutionary movement in Syria, albeit limited. In military terms, women's participation was minimal and negligible. Compulsory conscription in Syria is for males only. As a result of the prevailing culture, risks, and difficulties, most fighters in revolution and war were men. Some women were inside the Kurdish Syrian Democratic Forces (one of the military parties that fought in the war), but the main force was made up of men.

Healthcare workers spoke that this negligence was greater in the first period of the war due to the abrupt shifting of the medical priority and the extreme lack of resources:

*"As for the medical priority … most of the victims of the first period were militants and fighters. Frankly, the health staff was allocating more medical supplies to these injuries. Because people used to say that these fighters were fighting to protect us … surely, whoever comes to you with a gunshot is more important than the one who comes and has a headache or has, say, a stomach ulcer or so on. There was a kind of excessive sympathy for these injuries. They were more humane with those who came with life-threatening injuries." (M27, NUR)*

Field hospitals were described as primarily dedicated to treating war casualties therefore without the capacity to provide special care for vulnerable groups:

*"Vulnerable groups need special care. We do not have this thing available. We do not have the means to provide special care for children or a department for women and the elderly." (M46, DOC)*

Women faced additional burdens and obstacles in accessing treatment due to multiple factors, such as the absence of medical specialties for women's health, conservative communities who prefer the treating provider be female, and the marginalization of women in some camps. One participant described a severe shortage of midwives and gynecological specialties:

*"There were only two female gynecologists and six midwives. That number is too small for 1.5 million people. We had Caesarean sections and gynecological operations in very difficult conditions. On some days, there was no electricity, and on other days, there were massacres at the same time while we were working in the operating room." (M49, DOC)*

One participant highlighted how the conservative values of the places he worked in contributed to this issue:

*"Honestly, the customs of your community or your whereabouts interfere a lot with the medical work … we try very much to respect that. I mean, for example, when we were in the city of XXX, there were many ethnicities, and you feel that you have a little more freedom to work … for example, if the injured person were a female, you could work with her easily. But if you were in a field hospital, and the area was conservative or a little strict, then there would be some austerity or commitment to tradition … it happened to me on one occasion … where they brought us a 20-year-old female patient. So I looked and found that her brothers were by her side, and that they were the ones who had rescued her. There were female nurses, so I tried to walk away and let them do the job. This was welcomed by the brothers of the injured girl." (M27, NUR)*

One participant further described that the chaos during aid distribution for Syrian refugees led to the marginalization of women and children:

*"There was no way we could distribute aid fairly among all people. Because those who would reach us begin to jostle between people … there are people who would try to take the place of others. Of course, the family consisted of women only, and children were unfortunately marginalized. Because men always took the place and stood in line … we do not distribute aid 24 hours, and we do so at certain times." (M36, NUR)*

#### *<IP_ADDRESS> Lack of training in disaster ethics*

Most participants confirmed that they had not undergone any training in disaster ethics:

*"I have never been trained in this field. We missed this thing. It was not available." (M31, DOC)*

*"No, I did not receive any such training. But during our medical and surgical studies, we went through such subjects." (M46, DOC)*

*"No, I have not received any training." (M50, DOC)*

*"No, I didn't receive this training." (M49, DOC)*

*"No, I did not do that. It did not exist in the policy of the organization. The organization's support for employees was very poor. There were no training courses. This training is especially important in the case of war." (M25, NUR)*

*"No I did not undergo any training. Probably a colleague of mine teaches ethics in nursing. She gave only one lecture on the ethics of a registered nurse. Frankly, I have never done this." (F34, NUR)*

*"No honestly." (M27, NUR)*

*"Disaster ethics! Actually no." (M41, NUR)*

*"No!" (M29, NUR)*

*"Special training! No." (M30, PRO)*

*"No, I swear! I haven't received such training." (F32, PHA)*

*"There was no ethics training but only technical medical training. For ethics, generally, as I told you, we rely on personal morality." (M32, PHA)*

*"Training is badly needed. We would not have paid attention to this issue hadn't one of the workers said that he would act a certain way with the prisoners. This indicates a gap, but it was not visible. You cannot expect goodwill from all people. On the other hand … those workers who do not want to treat patients coming from the other side (the enemy) or want to misbehave with them, were good workers with religion and morals. But they missed this issue because they were not informed about it. It is important to conduct and repeat training courses in this regard. Then, the good person who missed this problem in the past, and the person who is willing to change, will change." (M47, DOC)*

*"There were no courses and lectures on ethics. But we were trained and other workers were educated on how to deal with injuries in the event of disasters, and on the method of triage. We did not give them any training in ethics in particular." (M55, DOC)*

*"Where are the specialists who did enter Syria now and opened institutes to train medical personnel on the principles of ethics!" (M50, DOC)*

*"Of course, training and qualification are not enough because the time is very short." (M50, DOC)*

Participants reported that medical ethics training was neglected even during their formal education:

*"Maybe I have received some training at the Red Crescent in triage. But you can't call that training in ethics. Even at our universities, you find that the subject of ethics is not attended by anyone, and what is discussed in the lecture is off-topic. They would bring you an old teacher to teach it, and the teacher would tell us stories during the lecture. Even at university, we did not get this proper education in ethics, and we have no idea about it." (M29, DOC)*

A foreign volunteer doctor who worked in Syria indicated that healthcare workers lacked medical ethics experiences:

*"I am sure that if the decisions were left to the doctors inside, they would not find the best ethical decisions. Because they have no experience in medical ethics, and they cannot balance it … it is up to the personal ethics of each doctor and what he or she has learned." (M44, DOC)*

Workers from different professional backgrounds also lack training in medical and professional ethics:

*"There are people from other professions who work in the health sector. They have no knowledge, or no detailed knowledge, about professional ethics. In fact, that's the case for most of us on this project." (M30, PRO)*

#### *<IP_ADDRESS> Justice, fairness, priority, and triage*

War conditions in Syria and the resource shortages present considerable challenges for the equitable distribution of medical care and services. Participants, in recounting the problems they faced distributing scarce resources and services, described that the greatest difficulty is determining what is fair distribution. Distribution methods and decisions considered unfair face backlash and criticism from patients, which adds pressure for healthcare workers:

*"Sometimes, people with certain injuries come to you … it can be a young active guy or a child. You can't give them a temporary prosthetic. You must give them a prosthetic that can handle running and jumping. This is a burden on you when another patient comes to you asking, 'why didn't you give me the same prosthesis! That is not fair!'." (M44, DOC)*

Some participants reported that vulnerable populations, such as women and children, were most affected by the inability to achieve justice in the distribution of aid:

*"There was no way we could distribute aid fairly among all people. Because those who would reach us begin to jostle between people … there are people who would try to take the place of others. Of course, the family consisted of women only, and children were unfortunately marginalized. Because men always took the place and stood in line … we do not distribute aid 24 hours, and we do so at certain times." (M36, NUR)*

Fairly allocating time spent with individual patients in the midst of a patient influx was another challenge cited by participants. In addition, they described that healthcare workers face great difficulty determining the priority of treatment:

*"The patient may need five minutes, but you will provide care in just two minutes to make room for others. Because you should know that if you have limited resources and spend five minutes on each patient, you will not be able to treat all patients. For example, today you have only 2 doctors and 1,000 patients. If each patient needed five minutes, I would be able to treat only about 100 to 200 patients out of the 1,000." (M36, NUR)*

According to some participants, the fair distribution of medical and humanitarian resources is directly related to the controlling military authority. The decisions were often based on security or military grounds rather than the issue of achieving justice in treatment, which complicated resource allocation for healthcare workers:

*"Sometimes, certain people are allowed to receive treatment and others are not. In this case, equality and equity in having access to health services will not be achieved. If it were up to us, we would accept patients regardless of their background. But here we are obligated to serve civilians only, and we are forbidden to serve fighters. And if you don't comply with the orders … you are in the army's area, and they decide." (M36, NUR)*

According to the participants, the use of force was employed in many cases to gain priority in treatment when dominant military forces ordered healthcare workers to treat some injured before others:

*"The militants don't wait for treatment; they want fast treatment and you have to accept that … I heard many stories. One was about armed men entering the hospital and frightening the doctors." (M44, DOC)*

*"Regarding medical triage cases … when the Assad regime controlled the situation, the soldiers of the regime might tell you to treat this casualty and leave the other. Then, the decision was never ours. That was an annoying thing." (M50, DOC)*

*"Although the hospitals were under the administration of the Health Directorate in Aleppo, they were under the control of the military groups. So, some groups acted ethically while others used bullying. They will order you to do this and that and to quickly treat some of the wounded." (M49, DOC)*

*"There were many situations where shooting took place within the medical center in order to force us to rescue an injured person and leave others who were injured." (M32, NUR)*

One participant (M36, NUR) is a thirty-six-year-old Jordanian nurse working in humanitarian and public health. He worked with Syrian refugees inside Syria and in Jordan. His service was limited to providing primary care, treatment for leishmaniosis patients, and general classification of patients for evacuation and follow-up treatment in Jordan. Since the area where he worked was close to the fighting, it was considered a military zone and therefore was under the orders of the Jordanian security authorities. This meant that, if ordered, he and his colleagues had to evacuate the area and leave patients in urgent need of care behind them, which caused stress for the workers.

Because of this experience, the participant stated that applying ethical principles can be difficult at times and in such circumstances. For example, due to his personal values, he preferred to provide care equally for all people. But when working with refugees in military-secured conflict zones governed by non-humanitarian authorities, he noted that achieving equality and justice, especially when assessing eligibility for treatment and the required health care, was not according to patients' needs and rights. To illustrate this, the participant shared the story of one of his colleagues who tried to arrange patient evacuations according to a specific medical priority rather than issues of security, leaving him with severe consequences:

*"My friend happened to be on one of the missions in difficult areas. He insisted that, for example, some patients should be treated in a certain way, and some should be evacuated and transferred for treatment only according to medical priority. Knowing that there was pressure exerted on him to evacuate and transfer certain patients for security reasons. Unfortunately, they tried to charge him with harassment and so on because he did not follow orders. The organization he works for was truly unable to defend him. He kept defending himself and telling them that they had to prove the accusations they had against him. There were investigations from within the organization and from the authorities, and they could not prove anything against him. They later came to know that the charges were malicious. However, the young man's dignity and reputation were hurt. I know this person personally. He used to say that he had worked a lot, but when he got into serious trouble, they left him to face it alone." (M36, NUR)*

Other participants described the role of emotion and its impact on decisions about the fairness of care, especially if the patient or injured person is a fellow healthcare worker or a relative:

*"Once, 13 injured young men came to us. While transporting the injured to us, it turned out that one of the injured was the son of one of our workers … may God have mercy on him … the healthcare worker collapsed and no longer realized what had happened … in another incident, one of our colleagues was injured, and he was an ambulance driver. So we couldn't control ourselves. We all ran to him from the medical center, and we all went with him in the ambulance. One of us was supposed to go with him, and the rest should have stayed at the medical center." (M32, NUR)*

In addition, stress and work pressure play a role in neglecting the issue of justice in treatment:

*"At a time when we were under severe pressure, the principle of medical justice was not respected. For example, the issue of priority in medical care was not respected." (M36, NUR)*

When distributing rehabilitation services from charitable organizations to war casualties, participants described ethical dilemmas related to a patient's interest versus the interest of society. For example, providing a free service to someone who can afford the price of the prosthesis places a dilemma on healthcare workers who also serve individuals unable to afford their services. In an environment with limited resources, this could lead to criticism from the rest of the clients:

*"Sometimes the patient would tell you that he would bring you parts of the prosthesis and ask you to fit them on his leg. This may indicate that he might have financial resources. So, how can you help him for free! You have a charitable project here that aims to help people who do not have money. So we got into a dilemma here. Do we agree on providing the service to people who have money or not? Especially since other patients would see this patient's prosthesis and may not believe that he bought it himself." (M44, DOC)*

The preference between quantity and quality for equitable resource distribution was cited as another ethical issue faced by healthcare workers:

*"We have to decide which prosthesis we use and which quality. Do we give ten people highquality prosthetics, or give one hundred people low-quality prosthetics?" (M44, DOC)*

One healthcare worker (M29, NUR), a 29-year-old nurse, worked as an emergency nurse for two field hospitals under a humanitarian medical organization in 2012, right before the start of the war in Syria. He started this job soon after graduating from university. He shared that working in Syria between 2012 and 2014 was his most difficult nursing experience because the field hospitals were close to a combat front. For instance, during his interview, the participant described caring for many injuries simultaneously and losing control of triage when both low-priority and critical cases were brought in by outside workers from the front lines to the at-capacity emergency department. This disrupted priority setting and the entire triage system erupted in chaos, creating an extreme situation where the participant and his colleagues did not know what to do and were no longer able to effectively work.

The chaos created ethical challenges and dilemmas related to prioritizing treatment in the event of mass casualties. It is essential to follow the priority settings in classifying patients according to the degree of risk and the need for urgent treatment because his issue can negatively affect rescuing the wounded, the use of resources, and the ability of medical personnel to rescue as many injured as possible. The participant described this event in thorough detail:

*"On that day, there was an attack … and a large number of casualties occurred … we reached a point where we could no longer control … there were workers … neither nurses nor doctors … who transport the patients … they take the injured into our department, according to the colors. This is a red case. This is a black case. This is green, so let him stay here. However, there was a kind of differentiation between the victims based on social ties. That is, there was someone who recognized this patient to be his friend, his brother's friend, or something similar, and the triage became like this … All patients were admitted directly to the emergency room, which was primarily intended for severe red cases. We had a large number of red and other cases flung to the ground. Among the injured people, there were two; one of them I knew personally, the other was unknown and needed a thoracentesis … the surgeon in charge of him was in the operating room to perform another operation.*  *The first patient had a gunshot wound to his neck … I gave him oxygen, and there were not enough oxygen generators. Therefore, I shared two patients with the same oxygen source using a piece of plastic … you lose control here … the other nurses were dealing with the patient who needed a thoracentesis. The nurses went to the operating room and asked the doctor for guidance, so he told them, 'I am doing surgery now, do I have to leave what's in my hands and get out!' As the nurses went to get equipment to do a thoracentesis, the anesthesiologist got there … he told them that he would do the thoracentesis, and he did it … we had one operating room… there were several injuries to the abdomen and small intestine, and the operations lasted four to five hours. Every new injury that needed an abdominal opening operation was directly sent to other hospitals. We were taking such decisions after we had this mess. As for the people who were injured in the limbs, we would stop the bleeding, compensate for the lack of fluid, and let them wait until we seek the surgeon's opinion … back to the patient who was injured in his neck; we noticed the deterioration of his condition, so we made a decision and sent him for treatment in Turkey. It took a long time for them to reach Turkey across the border. By the time they arrived at the hospital in Turkey, the patient had died. This was one of the most emotional and stressful days. I only told you about two examples, but the victims were all around. However, the two cases I mentioned occupied my mind during that time." (M29, NUR)*

Another participant (M39, NUR), a 39-year-old nurse with a master's degree in nursing, has provided medical care since the beginning of the revolution in 2011 in the liberated areas of Syria up until at least the time of the interview. During his tenure, he has experienced not only difficult care-related situations but also extremely dangerous situations, such as witnessing a shelling attack on the hospital he worked. During the interview, the participant shared a story where he rescued two children after a bombing near his house, but was faced with a dilemma of which child to provide life-sustaining resuscitation to while on the way to the hospital:

*"One time, in 2012, a house near where I live was bombed. A warplane came and dropped explosive barrels, and I was one of the people who helped two children. One was one and a half years old and the other six. One of the most difficult situations I faced was transporting these children from the scene of the accident to the hospital. The children needed resuscitation, and there was no one to help me with that … I tried to balance between the priorities of these two children. It was a difficult situation. Do I resuscitate this child or that child! Moreover, on what basis! You are in an unenviable position. Sometimes, in such situations, it is difficult to apply on the ground what you have learned in the academic field … you are in conflict … thank God, until I got to the hospital and the distance was about half an hour, the children arrived alive." (M39, NUR)*

Healthcare workers generally give priority treatment to the most critically ill patients where treatment is time sensitive. However, participants identified challenges in deciding priority when multiple individuals were critically injured with similar injuries:

*"When there is bombing and emergencies, I always start by helping the most seriously wounded. We tried as much as we could to help everyone we encountered. But in critical*  *situations, this was not the case. If you could wait, then you have to wait for half an hour, for example. To me, the priority was for someone who was at great risk … sometimes, you get two patients who cannot wait, or whose injuries are just as serious. You do not know whom to help first, and then you struggle among these victims and try to do your best." (M31, DOC)*

If the injuries were similar, some workers prioritized the young person over the elderly and women over men due to the prevailing cultural norms in the region:

*"If they bring me two injured people, one a young man and the other a child, and the two of them were in equally serious conditions, I would begin by treating the child because I'd say that the young man could bear his wounds a little. And if one of the injured were a woman and the other a man, then I would also begin by treating the woman because the man could bear his wounds … you also know that our societies are conservative, and there could be a lot of men in the emergency room, so it would be best to treat a woman first to protect her privacy." (M31, DOC)*

*"Treating children was often a priority over an old woman. For example, if there were an old woman who suffered from high blood pressure and was traumatized, we would try to send her to another hospital. In the case of a child, we would help him because he is more important than the old woman. This means that we postpone treatment of terminally ill patients." (F32, PHA)*

Participants also explained that sometimes services were provided on a first-come, first-served basis unless otherwise indicated by the doctor's recommendations or severity of other cases:

*"So far, we have worked on the standard that we give the prosthesis first to the patient who comes first … we used to accept the patient who comes first and install a prosthesis for him if there was no emergency. But if there was an emergency or a doctor's advice, we would change the priority. For example, if a person with a broken hip came to us, and the prosthesis helped him to stand and walk in order for the fracture to heal quickly, then he would have priority. So we were taking these cases into consideration and treating them quickly." (M30, PRO)*

Other participants described prioritizing treatable injuries over those whose injuries left little chance for recovery:

*"You should first classify cases according to priority and triage, and work on this basis. You have to start treating who could be saved from the wounded people. Cases with no hope of recovery would not be treated." (M46, DOC)*

*"War casualties are usually brought to us in great numbers. Some die, and others are classified according to their greatest need and critical condition. Some seriously injured people are left to die because there is no way to save them." (M49, DOC)*

In the examples shared by participants, it became clear that the number of healthcare workers available, the availability of resources, and how stressful the environment were important factors shaping priority setting and triage:

*"Do you deal with the most critical injuries or the least severe! How are decisions made? The issue is linked to the pressure and the availability of healthcare workers. All that is linked to the scarcity of resources … and the limited options available in our hands. This thing was causing … in addition to the amount of the massacres that happen … this thing was causing some conflict for doctors to determine and choose priorities." (M49, DOC)*

*"Capacity played a major role in the medical triage decision." (M29, DOC)*

Priority in treatment for other participants relied on rescuing and treating as many injured people as possible:

*"The rule was to save as many as possible. We used to start saving cases that could be treated quickly and so on, not the other way around … there are times when the most difficult case would be selected and sent to the operating room if the condition of the remaining cases allows waiting. But if the rest of the wounded could not wait, then I would choose the cases that I could treat faster, so that I leave room to save other cases. Of course, here we are talking about life-threatening cases. We are not talking about amputation. Amputations were treated … in the emergency department to stop the bleeding." (M29, DOC)*

According to some participants, the classification of the injured at the beginning of the war was often random due to the lack of experience and the number of volunteers without professional medical background:

*"Honestly, if we wanted to talk from the beginnings in 2012 and until 2014, there wasn't … I mean we weren't following something called triage. The work was random. The reason for this was the presence of volunteers among us. Even we as nurses, during our nursing studies, did not consider this issue and study it in depth." (M32, NUR)*

Emotions and kinship were described as other determining factors in clinical priority:

*"We were drawn more to the sights of blood and to those who cried more among the wounded. Sometimes it happened that we served first those we knew personally." (M32, NUR)*

*"Some moral values have not been respected at this moment … the injured were coming in succession. A nurse was trying to open a vein for someone in the triage room … and on the other side, there was a nurse trying the same for another patient, so the nurse shouted and said to her, 'is this not your husband!' So the nurse left her patient and became preoccupied instead with her husband. The rest of the healthcare workers did the same. Because she started crying and screaming loudly … her husband had a limb injury and a lot of bleeding. He was unconscious. So everyone tended to give him IV fluids because he is the husband of their co-worker … this thing also caused tension, and this is when the pressure started.*  *Here our interest in this close relative of a female worker has begun. The workers who care for the patients' transport … do not have any medical experience … they felt that this patient received better care because we know him, so they broke the rules in the triage. There was a lack of respect for these principles, and it was replaced by social relations … they allowed acquaintances and relatives to be treated first." (M29, NUR)*

Per the participants, determining priority is a strenuous burden for them and their colleagues, raising difficult questions that leave them wondering well beyond the moment whether their decisions are correct or if there is a possibility of saving more injured people:

*"Frankly, I started reading about the topics of guidance, ethics, and triage in early 2013. When I think of these questions that I've shared with you, I say to myself, oh God! Was it possible to save more than one! Was it better to treat this person before that one! Here, I read to look for justification. I want to find justification for myself." (M29, DOC)*

#### *<IP_ADDRESS> Neutrality, equality, and non-discrimination*

Participants in this code described how healthcare workers were required to abandon the principle of neutrality and follow the orders of controlling military forces:

*"Some of the armed factions told us that we were operating in the places they controlled, and, therefore, we were affiliated with them. We told them we are neither affiliated with you nor with others, we are doctors! The medical staff has nothing to do with that. They were not satisfied with what they heard from us. We were in trouble with the authorities who ruled in the area. There was no so-called neutrality." (M47, DOC)*

*"Some people got annoyed with us and said, 'why did you help the soldier!' On the other hand, the soldier asks you, 'why are you helping the rebels!'." (M50, DOC)*

*"I remember two clear cases where there were wounded members of the Assad regime. In both cases, there was pressure from the FSA (Free Syrian Army) for these wounded not to be treated. But we told them that we would not allow the wounded to be discharged from the hospital before treatment; otherwise, we will stop working. We succeeded in treating them with the usual triage method. Some might say this is wrong. But our work was correct and in the right order." (M29, DOC)*

According to the participants, the extreme violence practiced by the Assad regime against its opponents provoked an emotional reaction among healthcare workers. This reaction interfered with applying neutrality when dealing with wounded soldiers from the other side:

*"What happened to people as a result of the disasters that the Assad regime has caused! If the wounded were soldiers of the Syrian regime, the physician's or the nurse's treatment may not be 100% ethical. Why! Because this healthcare worker might have lost his brother, mother, father, or son due to the bombing of the regime forces, while now he has to treat a*  *wounded soldier from the regime! So the dealings with this soldier may not be 100 percent moral." (M55, DOC)*

*"Can you imagine that your enemy is bombing your hospital while you are asked to be totally ethical in dealing with war prisoners! If the residential areas, hospitals, schools, and bakeries were not a target of the bombardment, it would be then easier for workers to follow ethical standards in their dealings." (M49, DOC)*

One participant shared that, while working in Syria during the war, if it were identified by militants that an injured soldier of the other side was rescued, the primary goal of this rescue turned to interrogation rather than treatment:

*"When they rescue someone from the other side (enemy), they rescue him to question him and not to treat him … sometimes they say we need information, so we would have to question some prisoners. So the treatment will be to gain information." (M49, DOC)*

According to some participants, patients are sometimes discriminated against because of their political affiliation, dress, kinship, religion, or national origin:

*"There is arrogance in dealing with patients. For example, some healthcare workers say of patients, 'this is a displaced and this is a stranger'. They also say, 'we can't do better because the patient is in poor health'." (F34, NUR)*

*"There has been a lot of misconduct towards these values because people, you know, describe those who have been displaced or who have fled the war as "combatant families" without any justification … and they call them as terrorists. They are relating them and judging them depending on their dressing … there was discrimination among people depending on their background or their religion or depending on the area they are coming from." (M41, NUR)*

Participants spoke about the role of stress and pressure as factors influencing how they applied equality and non-discrimination during patient care. This meant that, under severe pressure, healthcare workers could choose to ignore patients with another religion or lead them to prioritize relatives:

*"Do circumstances allow me to apply these standards or not? There are patients of another religion who come to us … we certainly will not respect the principle of neutrality and equality if they come at a time when we are under such pressure. Because medical justice has not been respected in the case of those of the same faith as ours, who had varying injuries and were mostly categorized according to personal relationships. Others will be marginalized 100%." (M29, NUR)*

*"If two injured people came to me at a time when I am under a lot of stress, and then I found out that the beliefs of one of them are similar to mine … in the end, I will try morally to help everyone, but if I were under a certain pressure, and someone asked me to choose … then … I would surely help a person whose thoughts and religion are similar to mine." (M29, NUR)*

Participants identified instances where healthcare workers also faced discrimination. For example, some healthcare workers were fired or hired based on personal relationships, and differences in salaries, the way workers were treated, and the number of working hours were noted throughout the interviews:

*"We still have a problem with how to appoint someone as a manager in an organization. In one of the organizations, shortly after being appointed as a manager, he started getting rid of old employees. He wanted to hire his own people. So I asked him, 'why are you doing this!' He told me, 'I want to hire my own people, so I can do my work as I wish'." (M32, PHA)*

*"There is no equality. There are disparities in salaries, number of working hours, and shifts. There is even a disparity between … I mean, for example, as I told you, there are people who benefit from favoritism in other organizations, so their work and salaries are better than mine. It's all about the principle of equality." (M32, NUR)*

# **4.3.3 Corruption and organizational pressure**

# *<IP_ADDRESS> Corruption within the society*

The participants referred to the phenomenon of corruption rooted in society. This corruption includes dishonesty and workers' retreating from humanitarian goals in pursuit of narrow personal interests. According to participants, this corruption existed long before the war, thus exacerbating care-related challenges during the war:

*"We were doing our best but we could not … unfortunately, corruption is ingrained in our societies, and this is what they have instilled in us for forty years, until today. Whether this corruption is material or moral, the situation was like that in every sense of the word." (M31, DOC)*

The participants explained that the issue of corruption and moral retreat in society worsened after the revolution and the war:

*"The theme of ethics during the war is an important one and must be raised because we lost our ethics during the revolution and the war. Morality within the Syrian society is dead, and you no longer see the values that existed in 2011. It is true that morality was not at its height, but it was better than at present. Corruption has become deeply pervasive." (M31, DOC)*

For some participants, even the situations in opposition areas (i.e., liberated regions ruled by the rebels and outside the regime's control) are still not free from corruption. For example, participants described varying levels of corruption due to differences in ethical compliance among healthcare workers and in cases where some workers pursued self-interested goals:

*"People do not have a unified moral standard, and dreams are not so rosy, so there is corruption in the opposition areas. There are people who work only for their own interest and personal goals." (M49, DOC)*

*"Many doctors in the center worked for the sake of God. But, unfortunately, with the arrival of financial support, those working in healthcare services started changing over time. There are people whose goal is no longer to help but to make money." (M31, DOC)*

Participants shared examples where certain individuals and groups imposed financial fees on clients for services and medicines that humanitarian organizations would usually provide free of charge. The example below reveals a paradox a humanitarian aid, where it provides valuable support to those in need yet creates opportunities for abusers to manipulate its delivery:

*"We were surprised to find individuals there telling people that, 'if you are willing to pay money, we will allow you to receive healthcare faster'. For example, they also say to people, 'we will make it easier for you to get medicines, etc.' Of course, these individuals reside among the people in the camp. They were doing this propaganda so that people would come to them and pay them to get access to health care." (M36, NUR)*

### *<IP_ADDRESS> Favoritism and negligence*

Favoritism was identified by participants as one of the most common forms of corruption widespread in the health sector and within NGOs:

*"Favoritism was present in the medical community and prevalent among doctors or ordinary people who worked in the medical field. People are moving away from the goals for which they have revolted. Unfortunately, there is now favoritism and private interests in the revolution." (M31, DOC)*

*"Even I am working in a very high-level organization and we have, we can say, we have a minimum of problems related to these perspectives yet the influence is present. So the one who is related to this religion supports the group, his own group, and recruits the people from the same group … so the workers are related to their partners and everyone supporting his own group." (M41, NUR)*

*"In Syria, there is greed, and there are organizations that misuse politics and use favoritism." (M32, PHA)*

Priority in employment opportunities within the health sector, for example, was correlated to favoritism, and this led to injustice and loss of qualified workers:

*"There are a lot of people who deserve priority in jobs and are more qualified than others, but there is favoritism. This leads to the exclusion of qualified workers." (M25, NUR)*

According to some participants, favoritism, which they defined as favoring certain patients over others, created adverse effects on treatment priority. For example, in some cases, it caused patients to be neglected while others received better care:

*"Frankly, favoritism and nepotism increased dramatically … for example, your friend at work tells you that he will bring his wife to the hospital, and she will have priority in treatment. This thing, I do not hide from you, happens excessively. They are negligent … I mean, if our friend comes to the hospital, we can help her and give her the treatment, and follow her up in the hospital. But to neglect other patients for your own patient is absolutely against the principles. This person never applies these principles in his life." (F34, NUR)*

*"When the injured person arrived at the hospital, although his condition was not serious, the head of the department and the chief of nursing took care of him, even though there were others who were more seriously injured. The chief of nursing has run the entire department in his favor. Of course, there is a kinship between this patient and the chief of nursing, and therefore attention was paid to him." (M25, NUR)*

Participants described that some healthcare workers in Syria have taken advantage of their position for relatives or members of their sects by distributing medicines and medical equipment to them:

*"For example … medical equipment should not be taken out of the hospital. Sometimes relatives of the medical staff come to the hospital and ask for some medical equipment, bandages, and medicines. The medical staff usually give them what they want." (M25, NUR)*

*"Sectarianism is very prevalent in the villages. They say this sect is big and this is small. They have old enmities between them … we had some workers from the village, and sometimes they tried to discriminate while distributing medicines and so on. They are kind of biased or have preferences in favor of their people. So we are always in a dispute over this." (M32, NUR)*

The culture of nepotism and favoritism prevailing in the community and within the public and health sectors creates difficulties for healthcare workers. These difficulties have led to problems in the equitable distribution of health care and patients' suspicion of equal opportunities for treatment and services:

*"Sometimes, people with certain injuries come to you … It can be a young active guy or a child. You can't give them a temporary prosthetic. You must give them a prosthetic that can handle running and jumping. This is a burden on you when another patient comes to you asking, 'why didn't you give me the same prosthesis! That is not fair!' Then you must explain the case to him. But the patient often hardly understands this because he thinks that all people bribe and rely on favoritism." (M44, DOC)*

*"Unfortunately, our culture relies on nepotism. I have often fallen into embarrassing situations. For example, someone might come to tell you that someone else sent him to you, so that he gets more than his right to health services. Some days, I would tell them no! I apologize! But there are people who belong to a certain faction, or something like that, and get what they want by embarrassing healthcare workers and by relying on deception." (M32, PHA)*

### *<IP_ADDRESS> Lack of authority and accountability*

Participants indicated that the absence of regulatory, legislative, and even executive authority in areas outside the regime's control presents a unique challenge to applying ethical frameworks and principles. During times when authority was present, its role was often unclear and its influence was weak. In some cases, the executive management exercised authority, but often in accordance with the de facto authority's management style as it was incapable of organizing itself to complete monitoring, accountability, and regulatory functions. The lack of management on all accounts constitutes an impediment to addressing the problem of corruption and applying ethical standards and policies in health and humanitarian services:

*"Northern Syria has a very unique situation; it is not a government. It is not related to self-administration. No one knows what the political situation is, and no one takes responsibility. The ministry of health in northern Syria is very absent. Because it is not under the control of the Syrian government. So the self-administration has no capacity, and they are doing nothing in this respect." (M41, NUR)*

*"In Syria, in the countryside of Idlib and Aleppo, there is no entity that regulates the rights, and there are no state institutions to enforce the laws. If a certain standard is adopted, there is no authorized authority to implement it." (M30, PRO)*

*"We live in a state of war, and there are no laws in place. Nobody has authority over me in the medical center. I give medicine whenever I want, and I close my clinic whenever I want. There was no authority to regulate the work." (M32, NUR)*

Both the presence of corruption caused by the de facto authority and the lack of clear rules have disrupted the work of many health facilities, where each institution or organization relies on its own laws and standards and operates in an isolated, independent manner:

*"The de facto authorities caused problems. These authorities did not appreciate that you are filling a gap, and that they should help you and stand by you. The armed factions that entered the tug-of-war game supported them. Once, even the Civil Council stood against us. It was not a military faction but was controlled by two factions. The council told us that we must act according to their wishes. We said hello to them! But we will quit our job if these are the terms and hand you the responsibility! Then I went home and so did some of the healthcare workers while some others stayed in the hospital.  I told them I don't fight! The council includes two armed factions. Half an hour later, they called us and told us to stay at our workplace and that they would not interfere with our work. However, they continued to interfere, and this annoyed us." (M47, DOC)*

*"There is no good system, and there is corruption in these organizations … there is corruption, decentralization, favoritism, and poor organization and coordination, because there is*  *no health institution that oversees these organizations. Each organization acts as if it were a state in itself … there is a problem." (M46, DOC)*

One participant observed that implementing accountability was a problematic, systemic issue in Syria during the war. Healthcare workers critically needed clear, specific policies and ethical standards to follow and, moreover, be held accountable when violated, yet this did not exist:

*"It is very good to have an agreed-on standard. There needs to be an agreed-on academic standard to be followed in medical work instead of personal judgment. This provides protection for the worker in terms of both personal protection and decision-making. Therefore, he is not questioned about the reason for taking a specific action or decision instead of another. In this case, I have principles that I must follow." (M39, NUR)*

In turn, the lack of accountability increased errors and decreased feelings of guilt among healthcare workers, as described by one participant:

*"Some patients are in need. They offer their prosthesis on Facebook for sale … of course, the patient would install a prosthesis at our center, and later he would install a second and a third one at other centers, and so on … some of our technicians, who have a private center, tell us about that, 'oh, doctor! What can the patient do! He does not find food or drink. So the patient comes to me in my own center to sell me the prosthesis. I buy it from him, and I sell it and install it for another patient'. So, the patient installs the prosthesis in our charity center and then takes this prosthesis to sell it to some of our technicians who have a private center … of course, this is not free of charge; the worker takes a fee for the installation. The worker should instead return the prosthesis to us. However, he thinks that there is no problem with that. For him, it is not an issue of theft or breach of trust, nor a conflict of interest!" (M44, DOC)*

### *<IP_ADDRESS> Lack of monitoring and management*

The absence of authority during the war led to an absence in monitoring and management of healthcare workers. Participants who observed this described the difficulty in applying ethical values and standards that could help reduce corruption in the health sector:

*"I blame the health care management. I expect it to be the cause of corruption, whether in private or public hospitals, and whether they are supported by organizations or not. Because there is no monitoring … as I told you, when an employee or a medical staff see that no one is monitoring their work, so there is nothing left … just a little … I've never denied it … but there are only very few workers who adhere to ethical principles. Unfortunately, now everyone is just working as he pleases and things are a mess, and I won't talk any further." (F34, NUR)*

*"It is a matter of monitoring in the organization. Do the organizations ask themselves whether the supported health institutions apply the standards or not! Most organizations*  *provide support through intermediaries and do not know what happens afterward. They do not know where the resources go, and how they are distributed." (M32, NUR)*

The lack of monitoring led to chaos, a retreat of discipline, and caused tragic mistakes:

*"Sometimes, private prosthetic centers are set up. But those who work there know nothing about prosthetics. You might find a worker who works for two months in our center. Then he thinks he has become an expert in prosthetics, so he opens his own center afterward and then makes mistakes. Tragic cases come to us because of his mistakes." (M44, DOC)*

*<IP_ADDRESS> Lack of coordination and communication between health organizations themselves and between them and their healthcare workers*

Participants also reported an absence of coordination between health organizations and healthcare workers:

*"The systematization and coordination between work and the organization were absent … systematization may have existed, but it is poor." (M31, DOC)*

*"The medical staff in all the liberated areas do not care about rehabilitation … they take care of the patient before he enters the hospital, and then they transfer the patient to the hospital to take care of him until he passes the critical phase only. Otherwise, they give priority to others … this is due to poor coordination between the supporting organizations. Because the support organizations mainly support emergency medicine and only support … dealing with critical cases. The organizations do not give room, for example, to support physiotherapy, especially during war." (F34, NUR)*

Participants also observed poor coordination among medical and humanitarian organizations:

*"Unfortunately, there was some absence, or I wouldn't say absence, but I will say that if there had been more cooperation between the organizations, the work would have done twice as much. Unfortunately, there may have been some tension between the organizations, so there was not enough cooperation." (M32, PHA)*

*"There is corruption … and poor organization and coordination." (M46, DOC)*

Reasons cited for poor coordination included the absence of health institutions responsible for monitoring, lack of honesty, or prejudgment of intentions (the latter more common, according to participants):

*"There is … poor organization and coordination since there is no health institution that oversees these organizations." (M46, DOC)*

*"There is the issue of trustworthiness and premature judgment of intentions. These themes are common in our society and are deeply rooted therein." (M32, PHA)*

According to the participants, work communication sometimes depended prominently on trust, which led to negative results. In addition, participants identified the lack of a verification and follow-up mechanism while distributing medical assistance, thus increasing the possibility of corruption and misuse of resources:

*"Unfortunately, some hospitals have shown some greed … once, for example, they called in and told me that there was a severe shortage and so on. I went to see the hospital and did not find that they have a large number of patients. They told me that two days earlier, there was a bombing, and there were many patients in the hospital and the operating room. There was a person with us in the organization from the same town where the hospital is located. He told me that I could trust them and give them their needs. The quantity they needed was large, and there were more hospitals in need. Two days later, someone called me from this hospital and asked me if I was the one who had delivered the shipment of medical equipment. I said yes … he told me these people love assembling and stacking, and that they have a warehouse full of medical equipment and medicines. These medicines expire, and then they discard them. But it is important for them to collect such stuff. That's why they lie to medical companies and organizations and receive medicines and IV fluids. I do not know if they were selling them or not. But that makes it hard to find someone to trust." (M32, PHA)*

Another challenge described by participants occurred when healthcare workers no longer trusted external support organizations or the information these entities provided, considering them to be too far from the reality of the Syrian worker's daily difficulties and dangers:

*"Sometimes, there are people who believe that they know the context in which we live, but they are living on another planet. This is an ethical dilemma. They talk to health workers and cause trouble … frankly, and unfortunately, there is an obstacle to achieving trust between those providing support and information and the healthcare workers. The healthcare worker who works in this situation will tell them, 'I don't want to learn anything from you because you can't teach me anything useful'." (M29, DOC)*

One of the obstacles encountered by a participant providing services across health and humanitarian organizations was the absence of central patient data. As a result, when patients obtain medical services from different centers, healthcare workers are unable to access information about the patient's previous services or health conditions. This was identified as a critical factor hindering the fair distribution of services. One participant, a doctor who also served a management role, tried to initiate a central data system but failed due to a lack of trust between healthcare providers:

*"I have tried, through a major initiative, to create central data for the center of prosthetics. Several centers are operating, but there are no central data. The patient sometimes goes to a few centers and gets a prosthesis from each center. I have tried to do this, but there are difficulties. Every organization or institution believes that you want to acquire its patients.*  *There is always doubt when they have to give out information about the patients … there is always suspicion or ill intent that there is a story behind the data access." (M44, DOC)*

### *<IP_ADDRESS> External agendas of health and humanitarian organizations*

The participants talked about the existence of external agendas for medical and humanitarian organizations that may not be compatible with the requirements and orientations of health personnel. Some of these agendas were to be approved in exchange for financial support. The financial influx has shifted the goals of some healthcare workers towards financial gain rather than a commitment to humanitarian and ethical work.

*"At the end of 2015, I was trying to get away from medical organizations tied to agendas that I didn't know about. I could no longer accept this reality. My morals don't allow me. There were people working with you, but you could feel that their goal was the dollars and the support. External support and funding to achieve foreign agendas caused damage to the revolution." (M31, DOC)*

Some participants also spoke of their doubts concerning the relationship of some medical and humanitarian organizations to foreign political agendas and espionage purposes. Participants claimed that if the political goals of the bodies supporting these organizations changed or interests conflicted, the organization's work would be suddenly halted, leaving a significant medical and humanitarian services gap:

*"There are many organizations that come to us and join the work, claiming to be humanitarian organizations, but their goal is to collect information and spy for security institutions in several countries. They must choose between serving as intelligence service and working for a purely humanitarian purpose." (M55, DOC)*

*"We hope that these organizations would be honest and not participate in material or media gains, but only in humanitarian work! … not all organizations working in this field have a moral and humanitarian goal, sacrifice, and loyalty, but there are politicized organizations, and we have seen many of them fail. I am not generalizing to all organizations … we are protesting against all spies … they are agents of unknown countries." (M50, DOC)*

*"The work of organizations must be neutralized and separated from the political track. This means that humanitarian organizations should be humanitarian- oriented only, and not follow the policies of any country. I give you an example that happened in 2016 … there was an organization that took control of about seventy medical centers, and it was one of the largest, and its name was: XXX … the work of this organization was suspended by State XXX overnight. Imagine that 70 centers serving people in bombed areas, camps, etc. were closed. This decision is unethical on the part of the organization and the sponsoring country." (M32, NUR)*

*"Problems often arise between the international donor and the organization implementing the project. Then the international donor stops the project. This thing is very wrong. You should not stop the project … because the healthcare staff depend on it … you broke this … because you had a conflict with one of those responsible for implementing the project. In this case, you are just a materialistic person working for money and not sponsoring a humanitarian project as you claim." (M29, NUR)*

### *<IP_ADDRESS> Health organizations: Multiple ethical frameworks*

According to the participants, most of the organizations that contribute to medical and humanitarian work in Syria have their own policies and ethical standards and could contradict what others have adopted:

*"Each organization has its own ethical principles." (M50, DOC)*

Organizational differences in ethical standards and political goals have caused healthcare workers obstacles, stress, and confusion:

*"The different ethical and political orientations of the organizations caused a gap. For example, the Islamic organization Cham has a different approach than Doctors without Borders, SAMS, and SEMA. Therefore, framing these organizations within a framework that speaks about the regulations and ethics of the healthcare profession is very important." (M27, NUR)*

*"I've personally suffered from this problem. I work with MSF and follow certain ethics and standards. I have to change my principles when working with another organization that has other principles. It may be a local organization, and it may be a direct opposition to the regime. I would then have to abolish the principle of neutrality. They may tell you, for example, that if a pro-regime person comes to you, you should tell us directly, and we will do what is necessary. I will have to change my principles. It is good to have principles common to all the actors." (M29, NUR)*

Participants also explained that applying international medical standards and ethical frameworks, which many NGOs follow, could create additional difficulties, cause ethical conflicts, or have negative consequences due to the unique Syrian context and laws governing the country during the war:

*"In normal circumstances, when you treat a gunshot victim, you must write a report and hand it to the police; otherwise, you will be considered against the law. Can you do this in Syria during the war? If you do that, you'd be sending the casualty to his death! This issue is very important. Because it is also mentioned in the guidelines of the International Code of Conduct, that you have to act according to the local laws. But in Syria, if you act according to the local laws, you will be an immoral person." (M29, DOC)*

### *<IP_ADDRESS> Transparency, fidelity, and truth-telling*

Transparency was identified by many of the participants as the central, guiding principle expected from health organizations and institutions:

*"It is my right to get the institution's support in every step I take. And the transparency in dealing … I blame the leaders of sponsoring organizations, hospitals, and health centers for the poor quality of health care in Syria during the war. I blame them for not applying the moral values that are based on transparency in dealing." (F34, NUR)*

According to the participants, this problem was widespread in Syria before the revolution and the war:

*"In Syria, before the revolution, one of my friends had a cataract in his eye. I told him that he had to have the operation, and that there was a 5 percent chance of complications. Of course, I explained to him that there was a 95 percent success rate. He refused to have surgery. Another doctor saw me later and told me that I had scared the patient, that no one says so here, and that I should tell the patient that the operation is 100% successful. And If complications occur, I tell him that he moved his head, coughed, or moved his eye, or that his blood pressure increased during the operation. But you should never tell him that a medical error has occurred. I told myself, I would never go back to work in Syria under such circumstances. Unfortunately, the patient has no awareness and the doctor is in dilemma. If the doctor tries to be honest, he cannot work, and the patients will not accept him." (M44, DOC)*

The participants described the importance of honesty and faithfulness in work and noted that these values are somewhat lost during the war, which exacerbated corruption:

*"As a doctor, if you do not have honesty, faithfulness, and ethics in your work, you will not be successful, or your success may be only formal. Then you will not be able to respect and appreciate yourself, and you will feel guilty inside. Especially during the war … we are in a state of war and dire need of these principles. You have to imagine if there is corruption in these principles that will lead to the corruption of the whole society. Unfortunately, this is what happened … ethical principles have become forgotten in most of the Syrian society, especially in the medical community." (M31, DOC)*

*"In my personal opinion, and in general, the organizations do not work with honesty. Unfortunately, some people take advantage of the war situation to steal the resources that reach the organizations. They also take advantage of the hospitals' need for basic medical resources, and then steal the rest of the resources. This happens despite the large number of resources that reach health organizations." (F34, NUR)*

According to some participants, the motivation for personal gain, more commonly identified in regime-controlled areas, undermined honesty:

*"Adherence to medical regulations, standards, and procedures was less present during the war. Some people tried to profit from the crises at different levels, although they were less on the opposition than on Assad's side. For example, the director of the health department in the liberated area (opposition side) always instructed doctors about the exact fees for operations. But I have heard that some are taking more money than instructed. We are not prophets. The war circumstances do not allow everyone to be an angel." (M49, DOC)*

*"A technical worker made a trade, taking advantage of the patient's need. He told him he would provide him with a prosthesis from the private sector … a knee prosthesis … he brought him a prosthetic for \$2,000 (secretly). We found out. The artificial knee cost us only \$500. We warned the worker and punished him. We asked the patient to come back to us, and we refunded him and corrected the error. These are ethical issues that sometimes confuse workers. The worker did not see that there was a problem in his work. Rather, he said that he did so for the patient's convenience since he brought him the knee himself so the patient would not make any effort to get it. But he brought it to him and made a financial profit from it." (M44, DOC)*

One participant shared a personal story about concealing of a medical error and abandoning transparency to preserve the reputation of the health center, for a loss of reputation can lead to adverse effects in the community if they do not trust the care provided by the only medical center available in their region:

*"Once … we ran out of anesthetics … then we were able to get some after paying a lot of money … we got a substance called propofol … on that day, we were catering for a patient who had a previous amputation, and we wanted to do a debridement … and an abscess treatment … we used the propofol, but it caused the patient septic shock. The patient died of this septic shock. It was such a horrific issue because the patient was not in a serious condition. At first, we didn't understand the problem … then someone told us that we had to stop using this propofol because it is hand packed and not original. He told us that anyone who takes this propofol will show symptoms of septic shock. We kept quiet and didn't tell anyone about it. We were the only center providing medical service to that place, and there was no other center. Imagine the loss of reliability that would follow if our medicines were said to be spoiled! This thing has a huge impact on us." (M29, DOC)*

This participant said that he was often forced to lie during the war:

*"You may often have to lie." (M50, DOC)*

Another participant (M44, DOC) is a forty-four-year-old ophthalmologist. At the beginning of the Syrian uprising, he became involved in medical and rehabilitation work. The participant mentioned that he witnessed many tragedies from the continuous bombing of residential areas. During his interview, he described several challenges he experienced with specific ethical dilemmas, including the challenge of sharing bad news to the patient and patient's family that resulted from the scarcity of resources and a lack of specialists:

*"Several advanced injuries were brought to us … one of them was an 18-year-old girl who was injured in both eyes. Her sister was killed after the missile hit them while they were in the bathroom.  It was hard for us to decide whom to help first. We decided to treat the little girl and try to sew the cornea and remove the splinter from her eye because there was some hope. For the first girl, there was no hope as her injury was more serious and her eyes had to be removed. The problem lies in the fact that you can't remove them and you can't tell the family that you want to remove them. You have to run the operation and try, and then tell them we tried but that it was God's destiny. Then you can remove them. Of course, eye removal requires consultants, and this is not available in wartime. You always argue with yourself. I think frontline healthcare workers always face tough ethical decisions." (M44, DOC)*

#### **4.3.4 Psychological, emotional, and social stress**

#### *<IP_ADDRESS> Feelings of Syrian healthcare workers during the war*

Symptoms of anxiety, fear, confusion, and stress were expressed by participants when providing care in Syria due to the dangerous working conditions, deliberate targeting of medical facilities, and the complete loss of a sense of safety:

*"Your life as a healthcare worker is in danger. You are targeted by the Assad regime. Also, there is a lot of chaos and you can no longer distinguish between the fighting forces there. Even our armed men of the opposition descended into chaos. Anxiety, fatigue, and terror prevail every day." (M31, DOC)*

*"I am now sitting in the hospital without reassurance. Four hospitals in the northern countryside of Hama and Idlib were bombarded by Russia and the Assad regime in the recent campaign. These hospitals have become out of service. We can be bombed at any moment. There is never any protection for us." (M55, DOC)*

*"There were two main issues that caused me a lot of anxiety. Although I was living in the opposition's territories, there was no sense of security because of two things. Firstly, there was constant bombardment from the air, and secondly, you do not know the people around you. You could see, for example, many people wearing Djellaba (a loose cloak worn by Arab men) and growing beards. But you are unsure to whom they belong, maybe to the other side (the Assad regime side) or any other side … for us, as foreign doctors, (we were a team of six) it was hard, and, therefore, we had to walk only with trusted people and work anonymously with fake names." (M49, DOC)*

*"Sometimes, we were surprised that some clients were armed. Because we are here in desert areas. We sometimes hear gunfire from behind the border barrier on the Syrian side. Sometimes, it confuses and puts us under pressure." (M36, NUR)*

*"Imagine that the hospital receives the wounded due to the bombing (most of them are civilians, children, and women) in addition to the patients who are already in the hospital, and you have to secure them when the bombing occurs. So you are at a loss as to how to do*  *it. Well, whom should you secure! You must also secure yourself. We are in the hospital, and we hear the sounds of bombing, and the sounds of incoming warplanes and reconnaissance planes which are often followed by bombing. Here, you are confused and do not know where to go!" (M50, ANE)*

The participants shared the fear they experience anticipating the Assad regime forces recapturing their areas and thus punishing them for treating the regime's opponents:

*"The city of XXX was mainly under the control of the rebels. But there were military incursions into the city by the regime forces. Consequently, the party controlling the city was changing, once for the regime forces and once for the rebels. As a medical staff, we were afraid of being accused by the regime of treating the rebels." (M50, DOC)*

They also described a fear that healthcare workers would be kidnapped and abandoned, which increased their psychological pressure:

*"The organization I work for, a United Nations organization, told me that if I were kidnapped, it would be impossible to pay a ransom for my release, even if the kidnappers threatened to kill me. They don't say it outright, but this is the reality, and it puts you under a lot of psychological pressure." (M36, NUR)*

One of the participants still experienced flashbacks to his traumatic imprisonment and the accompanying suffering a few years ago when he was imprisoned for helping and treating opponents of the Assad regime:

*"Sometimes, when I'm alone, I start having flashbacks for about a minute. Then I can't sleep the next day, just imagining what happened to me." (M27, NUR)*

Participants shared tragic images and scenes they are unable to forget, leaving them with psychological scars:

*"I went through difficult experiences at the beginning of my work. It is when you see paralyzed children or children amputees. The first thing that comes to mind is that this child is not guilty and has no affiliation except for his country. These issues affect us the most. The issue of children and women … I encountered two or three such cases that I was severely affected by."  I have been through this experience.  You do not know the psychological effect this causes. These are unforgettable moments." (M31, DOC)*

The massacres that took place deeply affected the participants on a psychological level: