Celiac disease linked to common chemical pollutants

 

NYU LANGONE HEALTH / NYU SCHOOL OF MEDICINE

Elevated blood levels of toxic chemicals found in pesticides, nonstick cookware, and fire retardants have been tied to an increased risk for celiac disease in young people, new research shows.

According to NYU Grossman School of Medicine researchers who led the study, people with the immune disorder have severe gut reactions, including diarrhea and bloating, to foods containing gluten, a protein found in wheat, rye and barley. The only treatment is a gluten-free diet, with no bread, pasta, or cake, says lead investigator and doctoral student Abigail Gaylord, MPH.

Reporting in the journal Environmental Research online May 12, the NYU Langone team found that children and young adults with high blood levels of pesticides -- and with high levels of pesticide-related chemicals called dichlorodiphenyldichlorethylenes (DDEs) -- were twice as likely to be newly diagnosed with celiac disease as those without high levels.

The study also found that gender differences existed for celiac disease related to toxic exposures. For females, who make up the majority of celiac cases, higher-than-normal pesticide exposure meant they were at least eight times more likely to become gluten intolerant. Young females with elevated levels of nonstick chemicals, known as perflouoroalkyls, or PFAs, including products like Teflon, were five to nine times more likely to have celiac disease.

Young males, on the other hand, were twice as likely to be diagnosed with the disease if they had elevated blood levels of fire-retardant chemicals, polybrominated diphenyl ethers, or PBDEs.

Study co-investigator and health epidemiologist Leonardo Trasande, MD, MPP, the Jim G. Hendrick, MD Professor at NYU Langone, says further studies are needed to demonstrate that these toxic chemicals are a direct cause of celiac disease. But he noted that all are known to disrupt animal and human hormone levels, which are key to controlling both sexual development and immune defenses against infection.

Previous research has suggested that the origins of celiac disease, which afflicts one in 100 adults worldwide, were largely genetic and passed down from parents to offspring. Trasande, who also serves as chief of environmental pediatrics in the Department of Pediatrics at NYU Langone, and his colleagues wanted to investigate whether a link existed between environmental exposure to toxins and risk for a particular immune disorder directly affected by hormone levels, such as celiac disease.

"Our study establishes the first measureable tie-in between environmental exposure to toxic chemicals and celiac disease," says senior study investigator and pediatric gastroenterologist Jeremiah Levine, MD. "These results also raise the question of whether there are potential links between these chemicals and other autoimmune bowel diseases, which all warrant close monitoring and further study," says Levine, a professor in the Department of Pediatrics at NYU Langone.

Trasande says that if further studies show similar connections, such results could serve as evidence that the basis or underlying cause for many of these autoimmune disorders may not just be genetic, but also environmental.

For the study, researchers analyzed levels of toxic chemicals in the blood of 30 children and young adults, ages 3 to 21, who were newly diagnosed with celiac disease at NYU Langone Hassenfeld Children's Hospital. Test results were compared with those from 60 other young people of similar age, gender, and race. People with genes HLA-DQ2 and HLA-DQ8 are known to be at greater risk of being diagnosed with celiac disease. Other symptoms of celiac disease include diarrhea, fatigue, and anemia.

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Funding support for the study was provided by the KiDS of NYU Langone.

Besides Gaylord, Trasande, and Levine, other NYU Langone researchers involved in this study are Kurunthachalam Kannan, PhD; Kristen Thomas, MD; and Sunmi Lee, MS.

‘The grief is so unbearable’: Virus takes toll on Navajo

By FELICIA FONSECA and TIM SULLIVAN

TUBA CITY, Arizona (AP) — The virus arrived on the reservation in early March, when late winter winds were still blowing off the mesas and temperatures at dawn were often barely above freezing....

https://apnews.com/c77cc3c537c9a2510b67dcb631b4d988

AP PHOTOS: Volunteers flood Navajo Nation in virus outbreak

By CAROLYN KASTER

Under the watchful eye of Agathla Peak and just south of Monument Valley on the Navajo reservation, the Kayenta Health Center struggled under an onslaught of COVID-19.

https://apnews.com/11f67cac0b84aaa88834f6bc9179d138

TRUMP MINI ME

Pandemic politics costing lives in Brazil

AFP/File / EVARISTO SABrazilian President Jair Bolsonaro's (pictured May 6, 2020) criticism of stay-at-home measures to fight the virus has put him at odds with state and local authorities across Brazil, not to mention his own former health minister


Brazilian President Jair Bolsonaro keeps saying coronavirus fears are overblown. Other officials at the federal, state and local levels insist the danger is all too real.

Brazil is torn by a deep political divide over how to respond to the pandemic, and it is taking a heavy human toll.

On Saturday, even as the death toll in Brazil crossed the threshold of 10,000, Bolsonaro continued pressing to get the country back to work.

"The army of unemployed keeps growing," he tweeted.

"Is chaos coming?" added the far-right leader, who has compared the virus to a "little flu" and condemned the "hysteria" surrounding it.

Some argue the "chaos" is already here -- at least as far as the Brazilian government's response goes.

Bolsonaro's criticism of stay-at-home measures to fight the virus has put him at odds with state and local authorities across Brazil, not to mention his own former health minister.

The president sacked the latter, Luiz Henrique Mandetta, last month after a long series of public spats.

Meanwhile, Brazil has emerged as the epicenter of the pandemic in Latin America, with 11,519 deaths so far.

Experts say under-testing means the real figure is likely far higher, and that things stand to get a lot worse.

"We know from history that anytime there's such a cacophony in a situation like this, such huge disagreement on public policy among leaders, tragedy ensues," said Brazilian historian Sidney Chalhoub, a professor at Harvard University.

As an example, he cited the last major cholera outbreak in Europe, in the late 19th century, that killed more than 10,000 people in Hamburg, Germany.

"It was largely caused by divisions between the local political elite and dominant economic interests, which trumped public health concerns. And the result was an even bigger economic catastrophe," he said.

- Polarizing disease -

Bolsonaro supporters have held a series of anti-confinement protests in recent weeks.
 

AFP/File / EVARISTO SAPresident Jair Bolsonaro has sometimes joined his supporters protesting against quarantine and social distancing measures to combat the new coronavirus outbreak

Sometimes the president himself has joined in, hitting the street, shaking hands and giving fiery speeches, all while refusing to wear a face mask.

The protests have included virulent attacks on Congress and the Supreme Court, which have moved to counter Bolsonaro's anti-confinement measures.

At times, they have erupted into violence, including against journalists and even nurses.

But a recent poll by the Datafolha institute found that 67 percent of Brazilians believe stay-at-home measures are needed to contain the virus, even if they hurt the economy.

Even in his own camp, Bolsonaro's support is far from universal.

Another poll found that while 56 percent of those who call themselves right-wing or center-right supported the president's handling of the pandemic, 40 percent did not.

"The more closely related people are to someone who has been infected or died, the more they distance themselves from Bolsonaro," said political scientist Carlos Pereira of the Getulio Vargas Foundation, who conducted the latter poll.

- 'Anti-knowledge' -

Like his US counterpart Donald Trump, whom he admires, Bolsonaro has touted the medication chloroquine as a wonder drug against COVID-19.

AFP/File / JIM WATSONBrazilian President Jair Bolsonaro (L, pictured March 2020) has an outlook on aspects of the pandemic that is similar to his US counterpart Donald Trump


Scientists at Brazil's leading public health research institute, Fiocruz, have stated that preliminary studies do not indicate chloroquine is an effective treatment for the disease.

Perceived to be attacking the president, they have received threats on social media in response.

"We're talking about a far-right, anti-democratic government," some of whose supporters have "fascist" tendencies, said sociologist Debora Messenberg, of the University of Brasilia.

"We can't even talk about society being 'polarized' in the usual sense. It's not a democratic polarization. Right now, the debate is between democracy and authoritarianism," she said.

Brazil, like the United States, is facing the pandemic "with a government that is anti-knowledge," said Chalhoub.

The Bolsonaro administration "is depicting this as a public health catastrophe versus an economic catastrophe. But that's a harmful view that will drive us toward both," he said

Boom heard in Washington state likely an exploding meteor

May 8 (UPI) -- A loud booming sound reported by multiple witnesses in Washington state was likely a meteor exploding over the area, experts said.

The American Meteor Society said several reports came in about a bright object streaking across the sky over the Puget Sound area about 7 p.m. Wednesday, followed by a loud boom that some witnesses said caused their homes to shake.

"The more I read the more inclined I am to believe this was a fireball (which is a meteor that is larger and brighter than normal)," Bob Lunsford with the American Meteor Society told KOMO-TV. "I'm certain now that this was a meteoric event."

Lunsford said the timing of the sightings and the boom, which occurred about three minutes after the streak of light was noted, makes sense for a larger-than-normal meteor explosion.

"If this was larger than normal then the sound could have originated from a higher altitude. So a delay of 3 minutes is entirely possible," Lunsford said.

Space.com said the annual Eta Aquarid Meteor Shower, which is caused by Earth's orbit crossing through debris from Halley's Comet, peaked early Wednesday morning, but will continue to cause sightings for a few weeks.

Honey bees face chronic paralysis pandemic in Britain

New research suggests the chronic bee paralysis virus is spreading quickly among bee colonies in Britain. Photo by Ismael Mohamad/UPI | License Photo

May 1 (UPI) -- The virus responsible for chronic bee paralysis is spreading rapidly among honey bee colonies in Britain, according to a new study.

Between 2007 and 2017, scientists visited 24,000 beekeepers to survey the health of commercial bee colonies in England and Wales. In 2007, the disease was found only in Lincolnshire, a county in eastern England. Just ten years later, the virus had spread to 39 of 47 English and six of eight Welsh counties.

Though the virus was isolated among just a handful of colonies to start, it quickly made itself apparent. Researchers detailed the disease's spread in a new paper, published this week in the journal Nature Communications.

"The symptoms of the disease are quite easy to spot once you have seen them a few times," said lead study author Giles Budge, professor of environmental sciences at Newcastle University. "Symptoms of chronic bee paralysis can include shaking, black hairless bees with nibbled wings or shaking, greasy looking bees with dislocated wings. Bees can also simply shake too. Colony level symptoms include piles of dead bees right outside the front entrance."

RELATED Virus helps infected bees slip past the guards of healthy hives

Researchers used lab tests to confirm the presence of chronic bee paralysis virus at colonies where signs of infection were observed.

Bees infected by the virus usually die within weeks. Once infected, the disease can spread quickly among colony members. Roughly 40 percent of infected colonies are lost entirely, according to figures collected by Budge and his colleagues.

After surveying reports of the virus' spread, scientists confirmed that colonies managed by professional beekeepers, particularly those with imported queens, were more susceptible to the disease -- which were twice as quick to be infected by the virus.

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"Emerging diseases are tricky to study because the number of cases start low and then can build up rapidly," Budge said. "As such, we look for clues that highlight risk, and then we can try to explain why these heightened risks occur -- hence our observations on apiaries owned by professional beekeepers and those that contain imported queens."

A variety of management practices distinguish professional from amateur beekeeping, but scientists aren't yet sure why professionally managed bee colonies are more susceptible to the virus.

Though the disease can decimate entire colonies, the virus is distinct from the phenomenon known as colony collapse disorder, which was first reported in the United States. As well, pesticide exposure, while allowing the virus to replicate more quickly, doesn't appear to increase the risk that a colony will succumb to the virus.

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Still, researchers suggest the quickly spreading virus is a significant threat to bees and other insects.

"Honey bees are susceptible to many different viruses, and when considered in isolation, I'd argue that CBPV is one of the most important," Budge said. "This disease gets added as a pressure facing honey bees, although it is also worth noting that the virus can also infect other bees and ants, and so should be seen as an insect virus rather than a honey bee virus."

So far, scientists are ready to do little more than warn beekeepers of the threat of chronic bee paralysis virus, but Budge and his colleagues hope to identify effective mitigation strategies sooner rather than later.

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"We are part way through a four year program of research, and have a lot to do before we can advise on evidence based management strategies for chronic bee paralysis," he said. "We are working closely with the Bee Farmers Association, their members, and the national Bee Unit to achieve mitigation as our end goal."

Earthquake with magnitude of 3.8 detected in North Korea

IN THE OLD DAYS THIS WOULD HAVE BEEN CALLED A NUKE TEST BY THE WEST



South Korea issued this image of an earthquake detected in North Korea’s Kangwon Province Monday evening. Image courtesy of Republic of Korea Meteorological Administration

May 11 (UPI) -- A 3.8-magnitude earthquake was detected in North Korea's Kangwon Province on Monday evening, local time, according to South Korea's meteorological agency.

The tremor occurred at 7:45 p.m. in an area 20 miles north-northwest of Pyonggang County. The epicenter was monitored at 36.68 degrees north latitude and 128.18 degrees east longitude, Yonhap reported.

Seoul's weather agency initially reported a 4.0-magnitude earthquake, measuring the P wave or primary wave -- the fastest kind of seismic wave and the first to reach a seismic station. Six minutes later, the agency adjusted the number to 3.8, according to the report.

Multiple seismic stations across South Korea detected the quake in the North. At stations in Gangwon and Gyeonggi provinces, and in the cities of Seoul and Incheon, stations recorded a 2.0-magnitude tremor, Newsis reported.

The quake detected Monday evening is the strongest to be recorded on the Korean Peninsula this year.

In late January, Seoul reported a 2.5-magnitude earthquake in an area near North Korea's Punggye-ri nuclear site. The minor earthquake was believed to be at the time the result, or the aftermath, of North Korea's sixth nuclear test, which took place in September 2017.

On Sept. 21, 2019, Seoul said a 3.5-magnitude earthquake took place in North Korea.

On Monday, an official with Seoul's Meteorological Administration said the tremor appeared to be a "natural earthquake" and did not negatively impact the South.

ROGUE NATION USA
UNICEF: Release all children in detention during pandemic

Officials from UNICEF and the United Nations said detained children should be released across the world due to dangers from the coronavirus pandemic. Handout photo/Office of U.S. Congresswoman Doris Matsui/UPI | License Photo


May 11 (UPI) -- UNICEF and United Nations officials on Monday urged that all children held in detention around the world be immediately released during the COVID-19 crisis, including almost 200 held in Palestine.

Citing Israeli Prison Service detention reports that 194 Palestinian children were being held in detention at the end of March, officials from UNICEF and the UN's Human Rights Office called for Israel and the State of Palestine to release children, the majority of whom have not been convicted, but are awaiting trial.

"The rights of children to protection, safety and wellbeing must be upheld at all times. In normal times, the arrest or detention of a child should be a measure of last resort and for the shortest appropriate period of time," a joint statement from Genevieve Boutin, special representative for UNICEF in the State of Palestine, and James Heenan, head of the UN Human Rights Office said.

Children in detention are denied visitors and access to their parents and lawyers, officials said. Pandemic-related court delays are keeping children behind bars longer, especially because most are being detained while awaiting a hearing.

RELATED Judge orders Trump administration to speed release of migrant children

The statement follows a pandemic overview released by the UN Committee on the Rights of the Child, that recommends that because of dangers of COVID-19 children in detention should be immediately released from police institutions, prisons, secure centers, migration detention centers or camps.

Children are especially at-risk during the pandemic, an April statement from UNICEF director Henrietta Fore said.

"Detained children are ... more vulnerable to neglect, abuse and gender-based violence, especially if staffing levels or care are negatively impacted by the pandemic or containment measures," Fore said. "We call on governments and other detaining authorities to urgently release all children who can safely return to their families or an appropriate alternative."

In the United States, a California federal judge in April ordered the Trump administration to speed up the release of migrant children held in U.S. detention facilities, citing the risk of COVID-19. U.S. District Judge Dolly Gee said the U.S. violated the 1993 Flores Agreement, which said children cannot be detained longer than 20 days.

A United Nations report released in November initially claimed that more than 100,000 migrant children were being detained in the United States. That number was later revised downward to 69,000 by attorney Manfred Nowak, author of the Office of the High Commissioner for Human Rights' Global Study on Children Deprived of Liberty."

The report showed that the United States had the highest number of detained minors, followed by Mexico, with 18,000 children detained.

Survey: Atheists face discrimination, rejection in many areas of life

A stigma has prompted some nonreligious people to conceal their identity, a survey says. Photo by B_Me/Pixabay

May 11 (UPI) -- A new report says atheists in the United States face such widespread stigma and discrimination that many of them conceal their nonreligious identity from relatives, co-workers and people at school.

Atheist residents of "very religious" communities are especially likely to experience discrimination in education, employment and public services such as jury duty, according to Reality Check: Being Nonreligious in America, a survey released this month by American Atheists, a Cranford, N.J.-based nonprofit that advocates civil rights for nonreligious people.

The report says that although the percentage of Americans who consider themselves religious has been declining for decades and the diversity of religious beliefs has increased, nonreligious people "continue to live in a culture dominated by Christianity."

"Like religious minorities, nonreligious people too often face discrimination in various areas of life, as well as stigmatization, because of their beliefs," the report says.

Survey results

The report was based on the U.S. Secular Survey, which was created and managed by Strength in Numbers Consulting Group in New York. Nearly 34,000 participants age 18 or older who self-identified as atheists, agnostics, humanists, freethinkers, skeptics or secular people responded to the survey between Oct. 15 and Nov. 2.

"The Reality Check report reveals how widespread discrimination and stigma against nonreligious Americans is," American Atheists said in a news release. "Due to their nonreligious identity, more than half of survey participants had negative experiences with family members, nearly one-third in education and more than 1 in 5 in the workplace."

The percentage of survey respondents who mostly or always conceal their nonreligious identity from members of their immediate family was 31.4. The percent for co-workers was 44.3 and 42.8 for people at school, according to the report.

Among respondents under age 25, 21.9 percent reported their parents are not aware of their nonreligious beliefs. In that age group, 29.2 percent of those with parents who know about their nonreligious identity said they were somewhat or very unsupportive of their beliefs.

"We found that family rejection had a significant negative impact on participants' educational and psychological outcomes," the report says. "For example, participants with unsupportive parents had a 71.2 percent higher rate of likely depression than those with very supportive parents."

RELATED Poll: Almost half of Americans say Bible should influence U.S. laws

ALMOST HALF IS LESS THAN 50%

Geographic differences

The experiences of nonreligious people vary dramatically in different parts of the nation, Reality Check says. Nonreligious beliefs might be causally accepted in some states, including California and Vermont, but the stigmatization and concealment were higher on average in states survey participants reported as "very religious."

To reach those conclusions, survey participants were asked to assess how religious the people are in the community where they live and to rank the frequency -- never, seldom, sometimes, frequently or almost always -- that they had encountered nine types of "microaggressions" in the past year. Those experiences included being asked to go along with religious traditions to avoid stirring up trouble; being bothered by religious symbols or text in public places; being told they are not a "good person" because they are secular or nonreligious; and being asked by people to join them in thanking God for a fortunate event.

"As might be expected, participants from rural locations (49.6 percent) and small towns (42.7 percent) were more likely to say their current setting was 'very religious' than those from other settings (23.7 percent)," the report says. "Stigmatization and concealment were higher on average in states that participants reported are 'very religious.'"

The survey ranks Utah as the most religious state based on 80 percent of survey participants who live there calling their community "very religious." Mississippi is second with 78.7 percent.

Mississippi ranks as the worst state for stigma against nonreligious people and as the state where they are most often forced to conceal their beliefs. Utah is ranked as the second worst.

Sarah Worrel said she had friends of many faiths while growing up in Long Island, N.Y., and "you didn't presume someone was religious or of a particular religion until they told you." It's different in Mississippi, where she's lived since age 12.

"There's so little cultural diversity that it's assumed that you are some form of Christian unless you state otherwise," Worrel, the American Atheists assistant state director for Gulfport, wrote in an email. "I've met many atheists, pagans and other non-Christians here, but I usually don't find that out until I've gotten to know them well."

Worrel said she's had encounters with strangers trying to push religion on her and is always honest about her lack of belief but has not faced any serious discrimination. However, a friend lost a job for being an atheist, she said.

Questioning religion

Dan Ellis, the Utah state director for American Atheists, also is open about being an atheist.

Ellis said that as a child, he couldn't square what he learned in The Church of Jesus Christ of Latter-day Saints with stories of a Biblical flood that destroys everything. His teacher couldn't explain why a loving God would kill babies in such a cruel way, he said.

Ellis, who was never a firm believer, also was unable to get satisfactory answers to his questions from church leaders and as an adult, he eventually became a "Jack Mormon," a term for an inactive member of the LDS Church.

For a long time, he thought it was wrong to be a non-believer. He wasn't sure how to refer to himself until he was in his mid-20s and a co-worker revealed that he was an atheist. Ellis began using that label for himself with close friends and family.

At the time, people he knew linked atheism with satanism, he said. Ellis lost friends and angered some relatives, who cut him out of their lives.

"There's a lot of discrimination and recrimination in Utah against atheists," Ellis said, adding that many atheists can't be open about being nonreligious for fear of losing their job.

Overlooked viewpoint

Other survey findings include:

African-Americans who are nonreligious and ex-Muslims encounter significantly higher rates of discrimination and stigma.

Most participants were raised in the Christian religion, either in Protestant Christian (54.7 percent) or Catholic (29.9 percent) households. One in seven participants (14.3 percent) were raised in nonreligious households.

About 12 percent of survey participants reported being threatened in the past three years because of their secular identity.

Nick Fish, president of American Atheists, said in a news release that the struggles of nonreligious people are often overlooked.

"Thankfully, the U.S. Secular Survey has revealed the discrimination our community regularly faces," Fish said. "With that well-established, we need to find solutions and work toward ending the stigma faced by our community."

CHRISTIANITY THE GREATEST CREATOR OF ATHEISTS EVER 

5EYES

Space Force, global partners to receive 'Kobayashi Maru' space tracking system


Personnel at the Combined Space Operations Center at Vandenberg AFB Calif., review data for the U.S. Space Force, which announced development of new data and software for tracking objects in space on Friday. Photo by Maj. Cody Chiles/U.S. Air Force/UPI


May 11 (UPI) -- The U.S. Space Force announced the development of a software package to track and monitor objects in space.

The branch's Space Command and Control Program Office called the operational platform -- named Kobayashi Maru, for a training exercise depicted in a "Star Trek" episode -- a "breakthrough" of particular use to a five-nation coalition of space observers.

The United States, Britain, Australia, New Zealand and Canada comprise the FVEY, or "Five Eyes" Alliance, which provides joint cooperation in signals intelligence, human intelligence and other forms of military intelligence to its members.

Each government's intelligence community is involved in mutual collaboration. The United States' involvement includes the Central Intelligence Agency, the Defense Intelligence Agency, the FBI, the National Geospatial-Intelligence Agency and the National Security Agency.

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The new software, produced in a contract with California-based Palantir Technologies, "can host coalition-releasable mission workflows and applications for utilization by coalition exchange officers," Space Force said in a statement on Friday said. The contract was announced on April 14.

"The Space C2 -- Kobayashi Maru -- data-as-a-service platform will provide the United States Space Force a robust and flexible set of data streaming and storage technologies as well as data access patterns for the Space C2 system-of-systems," according to a program description obtained by Space News. "The vendor shall provide software licenses and professional services (as necessary) to implement this integrated platform and train users."

Its goal involves simplification of tracking of objects in space, referred to as "space domain awareness," with the opportunity to replicate all data by partner nations.

RELATED 'Space Fence' radar operational, tracks objects as small as 10 centimeters

"As a result of the new platform becoming operational, coalition members at the CSpOC -- Combined Space Operations Center -- can now fully employ the application, sharing that mission responsibility with our U.S. military members," said Col. Scott Brodeur, CSpOC director.

The data services will be tested at the Combined Space Operations Center at Vandenberg Air Force Base, Calif., and the National Space Defense Center at Schriever Air Force Base, Colo., the United States' primary locations for tracking orbital actions and objects in space.

Amnesty: Syria, Russia committed war crimes in anti-rebel push

Graffiti is seen on damaged building in war-torn Idlib province in northwest Syria, on April 23. Photo by Yahya Nemah/EPA-EFE

May 11 (UPI) -- Syrian government forces have committed a series of humanitarian violations that amount to "war crimes" in its campaign against rebels, Amnesty International said in an analysis Monday.

In a 40-page report titled "Nowhere is Safe For Us," the watchdog said Russian military and Syrian forces loyal to President Bashar al-Assad carried out a "new wave of horrors" against civilians in the opposition-held northwestern part of the country from May 2019 through March.

The human rights group said it documented 18 attacks on medical facilities and schools in Idlib, northwestern Hama and western Aleppo provinces -- mostly via airstrikes carried out by Russian and Syrian forces. Syrian fighters were blamed in three ground attacks and two barrel bomb attacks targeting civilians.

In one incident highlighted in the report, 11 civilians including a doctor and at least 30 civilians were injured in a series of airstrikes near al-Shami hospital in Ariha in January.

RELATED Turkish, Russian forces patrol key Syria corridor to uphold cease-fire

"I felt so helpless," a surviving doctor said. "My friend and colleague dying, children and women screaming outside... We were all paralyzed."

"In an all-too-familiar pattern,attacks from the air and the ground repeatedly struck residential areas and crucial infrastructure," Amnesty said in its report. "Yet even by the standards of this calamitous nine-year crisis, the resulting displacement and humanitarian emergency were unprecedented."

Based on its investigations, Amnesty said the attacks were not directed at any specific military objective and violated international prohibitions of direct attack of civilians.

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"These violations amount to war crimes," Amnesty concluded.

Assad's forces and Russian allies conducted an offensive in the region from December until a cease-fire in March. The fighting forced nearly 1 million civilians -- mostly women and children -- to flee toward the Turkish border.

The refugees packed makeshift shelters and camps set up in abandoned buildings and tens of thousands were forced to stay in open areas in freezing temperatures.

RELATED Erdogan threatens action to enforce cease-fire

Monday's report said humanitarian workers in northwest Syria are being hampered by the coronavirus pandemic and restrictions imposed by the largest group of rebels controlling the area, the Hay'at Tahrir al-Sham, which has been designated a terrorist group by the U.N. Security Council.