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Department of Psychiatry

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Epidemiology | International and Area Studies | International Public Health | Military, War, and Peace | Peace and Conflict Studies | Social Statistics


BACKGROUND: Since March, 2011, the Syrian civil war has lowered life expectancy by as much as 20 years. We describe demographic, spatial, and temporal patterns of direct deaths of civilians and opposition combatants from conflict-related violence in 6 years of war.

METHODS: We analysed conflict-related violent deaths with complete information on date, place, and cause of death and demographic group occurring from March 18, 2011, to Dec 31, 2016, recorded by the Violation Documentation Center (VDC). We included civilian and combatant deaths in all Syrian governorates, excluding government-controlled areas. We did not include detainees and missing persons, nor deaths from siege conditions or insufficient medical care. We categorised deaths based on VDC weapon type. We used chi(2) testing to compare deaths from different weapons in civilian men, women, boys, and girls and adult and child combatants. We analysed deaths by governorate and over time.

FINDINGS: The VDC recorded 143 630 conflict-related violent deaths with complete information between March 18, 2011, and Dec 31, 2016. Syrian civilians constituted 101 453 (70.6%) of the deaths compared with 42 177 (29.4%) opposition combatants. Direct deaths were caused by wide-area weapons of shelling and air bombardments in 58 099 (57.3%) civilians, including 8285 (74.6%) civilian women and 13 810 (79.4%) civilian children, and in 4058 (9.6%) opposition combatants. Proportions of children among civilian deaths increased from 8.9% (388 of 4254 civilian deaths) in 2011 to 19.0% (4927 of 25 972) in 2013 and to 23.3% (2662 of 11 444) in 2016. Of 7566 deaths from barrel bombs, 7351 (97.2%) were civilians, of whom 2007 (27.3%) were children. Of 20 281 deaths by execution, 18 747 (92.4%) were civilians and 1534 (7.6%) were opposition combatants. Compared with opposition child soldiers who were male (n=333), deaths of civilian male children (n=11 730) were caused more often by air bombardments (39.2% vs 5.4%, p < 0.0001) and shelling (37.3% vs 13.2%, p < 0.0001) and less often by shooting (12.5% vs 76.0%, p < 0.0001).

INTERPRETATION: Aerial bombing and shelling rapidly became primary causes of direct deaths of women and children and had disproportionate lethal effects on civilians, calling into question the use of wide-area explosive weapons in urban areas. Increased reliance on aerial bombing by the Syrian Government and international partners is likely to have contributed to findings that children were killed in increasing proportions over time, ultimately comprising a quarter of civilian deaths in 2016. The inordinate proportion of civilians among the executed is consistent with deliberate tactics to terrorise civilians. Deaths from barrel bombs were overwhelmingly civilian rather than opposition combatants, suggesting indiscriminate or targeted warfare contrary to international humanitarian law and possibly constituting a war crime.



Syria, civil war, conflict-related violent deaths, civilians, children, deaths, violence, causes of death

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Copyright © The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.

DOI of Published Version



Lancet Glob Health. 2018 Jan;6(1):e103-e110. doi: 10.1016/S2214-109X(17)30469-2. Epub 2017 Dec 7. Link to article on publisher's site

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The Lancet. Global health

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Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.