Executive Summary
On July 10, 2022, the United Nations Security Council Resolution 2585, which authorizes the use of the one remaining border crossing for humanitarian aid into Syria, Bab al-Hawa, will expire. If the United Nations Security Council (UNSC) allows it to lapse, the closing of this border will force six million Syrians to face grave uncertainty regarding the protection of their human rights, including basic needs essential for survival.
To inform this policy brief, PHR interviewed 20 health and humanitarian professionals and met with six humanitarian organizations who work in the region to gain insight into how life-saving aid currently flows to at-risk communities in Northern Syria, as well as how the potential closure of the lone remaining border crossing would impact Syrians’ health and wellbeing. The brief builds on PHR’s 11 years of rigorous research documenting the destruction of the Syrian health system.
Physicians for Human Rights (PHR) urges UNSC Member States to renew the Bab al-Hawa border crossing authorization for at least 12 months. PHR also calls on the UNSC to reauthorize the Bab al-Salaam and al-Yarubiyah crossing points, in order to ensure equal and adequate access to humanitarian aid for populations in need across all of northern Syria.
Introduction
In the 11 years since the Syrian conflict began, more than 14 million Syrians who remain in the country have required humanitarian assistance. More than four million people in northern Syria alone need regular humanitarian aid and, among those, 2.8 million are internally displaced persons. Without the lifelines represented by the UN cross-border operations, it will be challenging for millions of Syrians to access health care or become food secure. Currently, 80 percent of the population (12.4 million individuals) is food insecure, meaning they lack access to regular sources of safe and nutritious food. Among those 12.4 million people, 4.1 million are in northwest Syria, while 97 percent live below the global poverty line.
In 2014, the UNSC adopted resolution number 2165, which authorized the UN agencies and humanitarian partners to deliver humanitarian aids across conflict lines within the country (Cross-line) and by international border crossings (Cross-border) at Bab al-Hawa, Bab al- Salam, and al-Yarubiyah in northern Syria, and Al-Ramtha in the south.
Physicians for Human Rights urges UNSC Member States to renew the Bab al-Hawa border crossing authorization for at least 12 months.
The closure of the al-Yarubiya and Bab al-Salam border crossings in January and July 2020, respectively, resulted from Russia and China’s veto of draft resolutions to renew cross-border operations. At the moment, the Bab al-Hawa border crossing along the Syria-Türkiye frontier remains the only entry point for UN humanitarian aid to directly reach populations in northern Syria, which make up nearly a quarter of the Syrian population. Without the reauthorization of this crossing, Syrians in the northern part of the country will struggle to access humanitarian aid, exacerbating an already dire situation. Also, health organizations will lose access to essential medical supplies that are only available from the World Health Organization (WHO), including COVID-19 vaccines and other essential medications and medical equipment.
Physicians for Human Rights (PHR) urges UNSC member states to renew the Bab al-Hawa border crossing authorization for at least 12 months to offer certainty to NGOs and other humanitarian organizations to plan their programs in Syria. Failure to do so would have a devastating impact on a fragmented health system and will make it more challenging for Syrians to access health services in northern Syria. PHR also calls on member states to reauthorize the Bab al-Salaam and al-Yarubiyah crossing points in order to ensure equal and adequate access to humanitarian aid for populations in need across northern Syria. The closure of both these crossing points in 2020 has made major contributions to the near collapse of the public health care system in the northeast of Syria.
A Lifeline for North Syria
“The crossing point [in Bab al-Hawa] for millions of Syrians in the north is like the umbilical cord for a baby. It is vital for their survival.”
A physician and the mission director of a Syrian Medical NGO
Currently, northern Syria relies exclusively on the Bab al-Hawa border crossing to get all UN humanitarian aid and medical supplies to civilians. This crossing point is the key corridor through which the WHO can deliver COVID-19 vaccines and other essential supplies to millions in the northwest. Furthermore, Bab al-Hawa has been used by international and local NGOs to support the health system in northwest Syria with trauma care kits, surgical equipment, and medications.
According to the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA), 53.8 million beneficiaries have received health aid through the UN cross-border operations under the UNSC resolutions since the authorization of the operations in 2014. Of those, 46.5 million were reached from Türkiye through Bab al-Hawa and Bab al-Salaam, the latter of which was shuttered in 2020.3 The cross-border operations allowed children to receive their routine vaccines and facilitated the implementation of multiple rounds of polio campaigns. Following the declaration of COVID-19 as a global pandemic in 2020, the UN agencies have reached 18.5 million beneficiaries with medical supplies. If the UN Security Council votes to abruptly end the cross- border aid in northern Syria, an already catastrophic situation will be further exacerbated. Without these border crossings, there is no other well-equipped means to provide critical aid supplies at scale.
Weaponizing Health care
“If [the Syrian government] controls [the humanitarian aids], it will be a disaster. How should we expect the government that killed and displaced millions of people and used chemical weapons against civilians to distribute life-saving supplies?”
A physician from Afrin, North Syria
Resolution 2585, through which the UN Security Council extended by six months its previous authorization of the Bab al-Hawa crossing point, requested a special focus on different aid delivery modalities including crossline operations. Yet, according to UNOCHA, only five convoys have been deployed to northwest Syria since the Security Council’s most recent vote on this issue in July 2021.* These supplies were only sufficient for fewer than 200 thousand residents out of 2.9 million living in Idlib alone.
Health care providers in northwest Syria interviewed by PHR researchers voiced skepticism about claims that cross-line operations could or should substitute for the cross-border operations. An interviewee who previously volunteered with the Syrian Arab Red Crescent reported that the Syrian government has been selective in terms of the supplies that are allowed to enter the non- governmental-controlled areas. The interviewee noted, for instance, that surgical kits were not allowed to be delivered to the region. Also, a primary health care provider described that the Syrian government manipulated reports about vaccination rates in non-governmental controlled areas and deprived children of the right to access routine vaccines.
These views underscore a larger reality: for more than a decade, the Syrian government has systematically targeted health care workers, while using the health care system to brutalize and oppress the civilian population. Since March 2011, the Syrian government with the support of the Russian allies carried out at least 542 attacks on health care facilities, killed more than 850 health care providers, and arrested thousands of medical professionals. The Syrian government has routinely obstructed and denied access to health care to people living in areas of Syria it considers to be disloyal, even after retaking these areas, such as Daraa in southern Syria. As these statistics illustrate, allowing the Syrian government full control over the flow of humanitarian aid will have a devastating impact on the lives of millions of Syrians.
Lessons Learned from the Northeast
“Cross-line operations were covering 1% of the need and UN agencies in Damascus have been trying to increase the coverage by 35%. So, now 1.35% of the need will be covered.”
The head of a medical mission NGO in northeast Syria
In January 2020, the al-Yarubiyah crossing point was closed under UNSC Resolution 2504. Since then, the health system in northeast Syria has been struggling to meet the needs of affected populations, most recently evident in the unavailability of COVID-19 essential supplies.
Furthermore, relying on cross-line operations in the northeast has proven to be an inefficient alternative, as numerous local actors and medical professionals have reported to PHR and to the international news media. The WHO office in Damascus responded late to the COVID-19 pandemic in the northeast, which left the region with only one laboratory for PCR testing in the first six months of the pandemic.
Furthermore, prior to the closure of the al-Yarubiyah crossing, humanitarian organizations could receive humanitarian funds from the Türkiye Hub and implement health projects in the northeast through the border crossing. Currently, organizations can only receive funds directly from the Damascus Hub, which currently blocks most of the organizations from receiving such funds since they are required to be registered in Damascus to meet the eligibility criteria. Today, most organizations are not able to register in Damascus while maintaining their operations in northern Syria. Also, registering in Damascus requires that an NGO go through the Syria Trust for Development, which is founded by the First Lady Asma al-Assad, who remains under US sanctions as a result of the Caesar Syria Civilian Protection Act. Further, working in governmental-controlled areas requires working with the Syrian Red Crescent (SARC). PHR’s report on access to health in Daraa, southern Syria, shows that SARC has directed aid to areas within Daraa more firmly under the government control, withholding aid from areas that remained “opposition-minded.”
Medical supplies delivered by the Syrian government to the northeast have been grossly insufficient for the needs of the population, and they have not been distributed equally. In interviews with PHR, health care providers reported receiving medical supplies every five or six months that can barely cover their needs for a few days. In April 2022, the UN Secretary General estimated that cross-line operations provided around 850 thousand treatment courses for health facilities in the northeast. But these operations cannot fully replace the critical supplies that were delivered by the cross-border operations; NGOs supporting more than 100 health facilities in the region are still facing delays in securing essential medications, laboratory supplies, and treatment kits for communicable and non-communicable diseases due to barriers to access.
Obtaining necessary permissions from the Syrian government is also one of the challenges that delays the delivery of humanitarian aid to the region. According to the UNSC’s review of the UN’s humanitarian operations, the WHO delivered only two shipments by means of road convoys, both weighing 50,981 kg. Of those shipments, 67% were allocated for Qamishli National Hospital, which is run by the Syrian government, and the remaining 33% were distributed to 52 hospitals and medical centers. In short, the current situation in northeastern Syria illustrates the devastating, inequitable impact that the closure of operations at the Bab al-Hawa crossing point would have in the northwest.
Corruption and Retaliation
“When requesting supplies from Türkiye, these supplies enter Syria from the northwest and then are transported to the northeast, where different controlling parties impose high fees and taxes, and sometimes abduct part of the convoy. So, we end up receiving a portion of these supplies but at a very high cost.”
A physician working in northeast Syria
The health system in northeast Syria relies heavily on importing medical supplies and medications from government-controlled areas and on receiving supplies from Türkiye through the Bab al- Hawa crossing point, but both modalities are inefficient due to security reasons and logistical challenges. Health care providers in the northeast reported the impact of corruption at checkpoints between the government-controlled and the non-government-controlled territories, which has nearly tripled the cost of medical supplies compared to the prices in other governmental-controlled areas. This increase is due to the high fees and bribes that need to be paid, which can range from 10,000 to 15,000 US dollars per shipment, according to a director of a health care facility and a health care provider, who were interviewed by PHR researchers.
Regarding supplies arriving from the northwest, local NGOs and health care providers reported that shipments from the northwest are usually subjected to lengthy vetting procedures and/or theft while being transported through different areas of control. This is due to the political tension between the Syrian Democratic Forces and the opposition forces in the northwest and the Turkish-controlled territories. The Syrian government has used aid as a leverage to gain military wins in Aleppo, Homs, and Eastern Ghouta. The northwestern region, which remains the last standing opposition-controlled area in Syria and a vital refuge for millions of civilians who are afraid of and refuse to be in government-controlled areas, will face similar deprivation and retaliation if it is made to depend on cross-line humanitarian operations only.
According to the Humanitarian Needs Overview, the United Nations and its partners delivered humanitarian aid to 2.4 million individuals monthly, which falls short of meeting the needs of 3.4 million people in the northwest. Multiple modalities were used to scale up aid delivery, such as increasing the humanitarian aid flow through the cross-border and delivering through the cross- line operations. Still, even with this increase, the full needs of the population could not be met. Without a comprehensive strategy to implement a fair and equitable cross-line aid delivery that is adequate in size and scope, the cross-line cannot serve as an alternative to cross-border operations.
Recommendations
The health workers and experts interviewed by PHR emphasized that, for planning and staffing purposes, long term strategies that provide permanent solutions to the lack of medical supplies and services in northern Syria are necessary to ensure regular availability of, and access to, adequate health care in the region.
Given the shortcomings of cross-line humanitarian assistance between the Syrian government and non-government-held territory, comprising northwest Syria, northeast Syria, and Turkish- controlled areas, efficient delivery of humanitarian assistance to northern Syria must continue through the cross-border to meet population needs. Unless a holistic plan is designed that allows gradual and monitored integration of cross-line aid in the northwest, as well as mobilization of international humanitarian organizations, closing the Bab al-Hawa border in July will have dire consequences on the health of millions of Syrians.
PHR calls on the parties concerned to take the following actions:
To UNSC Member States:
- Authorize the renewal of cross-border resolution 2165 to maintain the Bab al-Hawa border crossing in northwest Syria beyond one year;
- Reopen the Bab al-Salam and al-Yarubiya border crossings to meet the demonstrated need of the population, considering Syria’s failing health system and the gravity of COVID-19 pandemic; and
- Call upon the Syrian government to ensure the delivery of aid and allocation of health services so that the WHO and other UN agencies, as well as humanitarian organizations and local actors, can reach populations in a neutral, effective, and equitable manner.
To the Syrian Arab Republic:
- Comply with minimum standards for coordination of humanitarian health system rehabilitation to avoid inequitable access to health care;
- Adopt transparent measures to prevent diversion of assistance;
- Provide donors with accounts of aid distribution in areas under the control of the Syrian government, including COVID-19 access to training, testing, PPE, equipment, treatment, and vaccines; and
- End attacks on health care workers, facilities, and transports.
*The number of UN inter-agency cross-line convoys was updated on June 14, 2022.