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Obstruction and Denial: Health System Disparities and COVID-19 in Daraa, Syria

Obstruction and Denial: Health System Disparities and COVID-19 in Daraa, Syria

Executive Summary

In March 2011, following the uprisings throughout the Middle East known as the Arab Spring, civilian protests against the government of Syrian President Bashar al-Assad broke out in Daraa City, the capital of Daraa governorate in southern Syria.[1] The popular uprisings that drove the revolution were triggered when Syrians nationwide witnessed video footage circulated online of the corpse of 13-year-old Hamza Ali al-Khateeb from rural Daraa – who was taken into government custody after attending a peaceful protest – showing clear evidence of torture, including genital mutilation. Peaceful protests throughout the country ensued, followed by a brutal government response and military crackdowns on protestors and other civilians.

In June 2018, the Syrian government and its Russian allies began a military offensive against opposition forces in Daraa that displaced more than 270,000 civilians from across southern Syria.[2] Health facilities were a primary target of airstrikes, reportedly in order to deprive local populations of essential services and to pressure opposition leaders to submit.[3] After fierce aerial bombing, the government and its Russian allies offered opposition leaders “reconciliation agreements,” negotiated truces that would allow for a return to life under government control and full access to public services, presumably including health care.[4] Daraa was retaken by the government over the next months, and the offensive ended in August 2018.[5] As the Syrian government has regained control of opposition-held territories like Daraa, the pattern of violence has shifted to include reprisals, willful neglect, denial of access for humanitarian services, suppression of information, and arbitrary withholding of aid. 

A human rights crisis lies at the origin of the humanitarian crisis in Syria. Physicians for Human Rights (PHR) has documented human rights violations, including attacks on health care facilities and personnel, and the arrest, detention, and torture of health care workers, since the beginning of the Syrian conflict in 2011. The Syrian government’s systematic destruction of health facility infrastructure, targeted assassinations and kidnappings of health care workers, and obstruction of population movement in opposition-held areas have led to a health system that fails to respond to basic health needs, let alone to the COVID-19 pandemic. By the end of December 2019, nearly 50 percent of hospitals in government-controlled areas had experienced partial or full damage of their facilities, and 19 percent were considered only partially accessible or inaccessible.[6]  

The Syrian government’s systematic destruction of health facility infrastructure, targeted assassinations and kidnappings of health care workers, and obstruction of population movement in opposition-held areas have led to a health system that fails to respond to basic health needs, let alone to the COVID-19 pandemic.

For this report, PHR researchers conducted 19 key informant interviews between August and October 2020 using remote communication methods. Key informants included humanitarian workers, research analysts, academics, and journalists, based in Jordan, Lebanon, Syria, Turkey, the United Kingdom, and the United States.

Key informants had close contacts inside Daraa, a working knowledge of the health system in Daraa before and after reconciliation, and/or familiarity with COVID-19 in Daraa. The interviews were supplemented by a desk research review regarding COVID-19 and health system trends in Daraa and in southern Syria, more broadly. Despite limitations in the ability to conduct interviews with health care workers or other health stakeholders inside Daraa due to security reasons, this report corroborates accounts from multiple stakeholders with contacts inside Daraa which point to the systematic and intentional neglect by the Syrian government of the overall health system and COVID-19 response effort within the southern governorate.

This report examines factors contributing to the health system decline in Daraa since 2018, when the area was retaken by the Syrian government. As part of the reconciliation agreements, the government reportedly agreed to reinstate all dismissed government employees, including former Ministry of Health employees, and to rebuild civil government institutions such as the public health sector.[7] However, according to report findings, the Syrian government has done little to rebuild areas formerly under opposition control or to replace the essential health services that were provided by the humanitarian organizations that were forced to withdraw following the government takeover of the area. The Syrian government heavily regulates the handful of UN agencies and international non-governmental organizations (NGOs) who continue to support health programs in the south by limiting permissions for NGO registration and access, taking excessively long to approve projects, and restricting monitoring visits. As a result, Daraa’s health system remains largely destroyed and under-resourced; two years after reconciliation, most of Daraa’s population has no access to adequate health services, with estimates indicating that more than 446,000 civilians in Daraa are considered persons in need of humanitarian aid.[8] Further, interviewees indicated that the government routinely diverts aid through recipient lists that are given to the Syrian Arab Red Crescent only after security personnel have removed the families of people blacklisted by the regime. The government’s restriction of humanitarian aid to areas it deems disloyal and the illegal diversion of the humanitarian assistance that is permitted to enter violates established humanitarian principles.

The report also explores the impact of Syrian government control of access to health care in Daraa since reconciliation, including during the COVID-19 pandemic. Patients, especially those with chronic health conditions, were already struggling to receive necessary care before March 22, 2020, when the first cases of COVID-19 in Syria were acknowledged by the government. Facilities are now reportedly overwhelmed with the COVID-19 caseload. Although official reports indicate no more than 7,887 cases of COVID-19 (and 417 deaths) in government-controlled areas since reporting began in March, there is widespread consensus, even from within the Syrian government, that these numbers do not capture the true caseload.[9],[10],[11] The government has suppressed public information about the pandemic and testing capacity remains woefully inadequate; there are no laboratories capable of processing COVID-19 test samples in Daraa.[12]In short, Daraa’s health system is undersupplied, understaffed, and incapable of handling a more widespread COVID-19 outbreak.

Daraa’s health system has suffered from repeated attacks on its facilities and personnel throughout the years of conflict. In comparison to other parts of Syria, Daraa has lost the greatest proportion of hospital beds since the conflict began: in 2019, the in-patient capacity of its public hospitals was 310 beds, versus the pre-conflict capacity of 810 beds.[13]Of the eight “national” or public hospitals in Daraa, only one, in Daraa City, is fully functioning.[14]In addition to the physical damage to the health system in Daraa, the health care workforce has also suffered from years of government targeting and neglect and shortages of health care workers are a major impediment to civilian health care access. Significant displacements occurred in Daraa during the uptick in hostilities in 2018, and likely included qualified health care workers who worked for humanitarian aid organizations, who were particularly fearful of violence and retribution from government security forces.[15] Requirements that health care providers undergo individual reconciliation processes have exacerbated the shortages, as many were reportedly denied security clearance and have not been able to return to work in the public sector.[16] The health care worker shortage in Daraa serves as an example of how the government has handled the provision of health services in areas retaken from the opposition compared to loyalist areas; in 2019, the number of doctors per 10,000 residents in Daraa was 1.1, while in Damascus, it was 20.3 and in Latakia, 15.3.[17]

As the Syrian government has regained control of opposition-held territories like Daraa, the pattern of violence has shifted to include reprisals, willful neglect, denial of access for humanitarian services, suppression of information, and arbitrary withholding of aid. 

Mseifra Hospital in Daraa after being struck by air strikes in June 2018, during the Syrian government’s push to retake the opposition-held area. Of the eight “national” or public hospitals in Daraa, only one, in Daraa City, is fully functioning. Photo: Mohamad Abazeed/AFP/Getty Images

Findings from this study also warn of the risk COVID-19 poses to areas outside of Damascus, and particularly, recently reconciled areas such as Daraa, where health professionals and facilities have little access to personal protective equipment, testing kits, and the means to monitor and treat severe cases. Furthermore, the pandemic has struck Syria at a particularly challenging time for the economy; sanctions imposed by the European Union and the United States have contributed greatly to the currency devaluation.[18] The weakened economy has impacted access to health care in Daraa, where government-provided services are inadequate, and patients must pay for transportation to functioning public facilities or seek care in the costly private sector. As with most secondary health services since reconciliation, severe COVID-19 cases in Daraa require transfer to Damascus. In addition to being beyond the financial means of most Daraa residents, travel to Damascus, or even between some towns within the governorate, is not possible due to the volatile security situation. In addition to the general lawlessness and criminality that is reportedly on the rise, many people, particularly young men, fear being detained at checkpoints, which have increased in the COVID-19 era.[19]Young men may be apprehended at a checkpoint because their “reconciliation card” may not be accepted, they are wanted by the government for opposition involvement, or they have not completed the compulsory military service. Both the crumbling economy and the increasing physical insecurity for civilians have intensified patients’ inability to access care, including treatment for COVID-19, in Daraa.

Governments, the United Nations, and international humanitarian organizations with the ability to advocate, act, and influence the Syrian government to expand its COVID-19 response strategies must be well-informed by timely, reliable data from the Ministry of Health and the World Health Organization of the current health situation in reconciled areas. The government of Syria and humanitarian organizations must improve their COVID-19 preparedness and response efforts in southern Syria in order to prevent successive waves of COVID-19 within Syria, in surrounding countries (such as neighboring Jordan), and in the region, as well as future pandemics. While humanitarian assistance is badly needed, donors and agencies must also demand transparency and accountability for aid.

Daraa’s health system remains largely destroyed and under-resourced; two years after reconciliation, most of Daraa’s population has no access to adequate health services.

Given the deterioration of the security situation and profound economic pressures, governments, international humanitarian organizations, and the United Nations must urge the Syrian government both to expand its COVID-19 response strategies and to commit to an equitable distribution of health resources informed by transparent reporting of health data from reconciled areas. In particular, the health system in Daraa – a region adjacent to both Jordan and the Golan Heights, and whose population the government considers disloyal – is in dire need of supplies and personnel to prevent the spread of COVID-19 within Syria and to neighboring countries. The Syrian government’s failure to rebuild essential health system infrastructure and invest in the health care workforce, its withholding of access to humanitarian aid, and its restrictions on data collection and dissemination have all contributed to the failure of the health system in Daraa, which now struggles to respond to the COVID-19 pandemic.

Key Recommendations:

To the Syrian Arab Republic:

  • Lift barriers for reconciled health care workers seeking public sector employment;
  • Expand access for desperately needed humanitarian aid to areas retaken by the government, and those areas still held by the opposition;
  • Adopt transparent measures to prevent diversion of assistance and provide donors with accounts of aid distribution in reconciled areas, including COVID-19 testing and personal protective equipment distribution;
  • Verify that public sector services, as well as services provided by the Syrian Arab Red Crescent, are equitable and accessible to all civilians and not distributed based on discriminatory or preferential measures; and
  • Ensure that the Ministry of Health allows full access to World Health Organization field workers deployed to assess the situation in Daraa.

PHR recognizes that the Syrian government’s longstanding persecution of health care workers continues with impunity and reiterates these recommendations to the government:

  • Stop intimidating, threatening, arresting, disappearing, torturing, and killing health care workers.
  • Release all those arbitrarily detained or persecuted for carrying out their medical duties and exercising their basic human rights.

To Humanitarian Actors and Implementing Organizations:

  • Conduct independent needs assessments to ensure equitable service provision and inform coordination. Monitoring of medication and supplies will also provide local and international communities with information necessary to understand the health system’s preparedness in Daraa to respond to COVID-19 and other health needs.

To the UN Security Council and UN Member States:

  • Demand the distribution of timely, detailed epidemiological information about the extent of the COVID-19 pandemic consistent with the right to information.

To Jordan, Turkey, and the United States, Guarantors of the Southern De-escalation Zone:

  • Exert pressure on the government of Syria to include the health system in any negotiated settlements and facilitate humanitarian access by increasing security, travel permits, independent data collection, and publication of health system data.

To Donors:

  • Address indications that the Daraa health system is near collapse. In Daraa and in other areas retaken by the Syrian government, where the government is unable or unwilling to provide funding and resources for the most basic health services, humanitarian assistance should be extended.

Introduction

Since the beginning of the Syrian conflict in 2011, Physicians for Human Rights (PHR) has documented human rights violations against the health system in Syria, using evidence-based research and field perspectives to advocate for protection and accountability. PHR’s ongoing documentation of attacks on health care facilities and personnel has revealed a systematic assault on health in Syria, and the arrest, detention, and torture of health care workers.[20] The Syrian conflict has led to the largest number of forcibly displaced people worldwide, with more than 5.5 million Syrians registered as refugees in neighboring countries and more than 6.2 million internally displaced people inside the country.[21] Nearly 11.7 million people in Syria are in need of humanitarian assistance. Estimates indicate that more than 400,000 Syrians have been killed since 2011, a number which has neither been confirmed nor updated since 2014.[22] Damage to physical infrastructure in Syria is significant, with losses in gross domestic product estimated to be $226 billion between 2011 and the end of 2016. According to a 2017 World Bank assessment, approximately 54 percent of all hospitals in 10 cities experienced some degree of damage.[23] More recent data indicates that by the end of December 2019, nearly 50 percent of hospitals in government-controlled areas had experienced partial or full damage of their facilities, and 19 percent were considered partially accessible or inaccessible.[24]

Health facilities were a primary target of airstrikes, a war strategy used to deprive local populations of essential services and to pressure opposition leaders to submit.

Before the onset of the Syrian conflict, Daraa governorate in southwestern Syria had a population of almost 844,000.[25] A governorate of 1,440 square miles,[26] Daraa was historically among the poorest of Syria’s 14 governorates, with a rural economy and a traditional social structure based on strong tribal networks.[27] By the end of 2010, the economy in southern and eastern Syria collapsed due to drought, lack of development, and the government’s mismanagement of resources.[28]

In March 2011, following the uprisings throughout the Middle East known as the Arab Spring, civilian protest against the government of Syrian President Bashar al-Assad broke out in Daraa City, the capital of Daraa governorate. Syrian intelligence officers detained and tortured adolescent boys for days after they were caught writing anti-Assad graffiti.[29] The popular uprisings that drove the revolution were triggered when Syrians nationwide witnessed video footage circulated online of the corpse of 13-year-old Hamza Ali al-Khateeb from rural Daraa – who was taken into government custody after attending a peaceful protest – showing clear evidence of torture, including genital mutilation.[30] Peaceful protests throughout the country ensued, followed by a brutal government response.

Military crackdowns on civilian protestors by the Syrian government mobilized the tight-knit population of Daraa into armed resistance and the governorate into an opposition stronghold, which it remained until 2018. Between 2012 and 2018, opposition forces maintained control of a large part of Daraa governorate, including Daraa al-Balad, the southern half of the capital, Daraa City. In addition to this legacy of defiance, Daraa’s strategic location bordering Jordan and the Israeli-occupied Golan Heights made it a priority for the Syrian government to reconquer.

People carry a wounded Syrian to the hospital in a pick-up truck in June 2018, during the Syrian
government’s campaign to retake Daraa governorate. Photo: Malik Abo Obida/Anadolu Agency/Getty Images

In June 2018, the Syrian government and its Russian allies began a military offensive that displaced more than 270,000 civilians from across southern Syria.[31] As of 2014, the Syrian Central Bureau of Statistics estimated that the population of Daraa was just over 680,000, but, given these displacements, the current population of Daraa could be smaller.[32] Health facilities were a primary target of airstrikes, a war strategy used to deprive local populations of essential services and to pressure opposition leaders to submit.[33] After fierce aerial bombing, the government offered opposition leaders reconciliation agreements, negotiated truces that would allow for a return to life under government control and full access to public services, presumably including health care. Daraa was retaken by the government over the next months, and the offensive ended in August 2018.[34]

Daraa’s struggling health system is the result of a decade of human rights abuses against the Syrian people by the government and its allies.

The COVID-19 pandemic has posed widespread health threats throughout Syria, including to health care workers caring for affected populations. Although official reports indicate no more than 6,684 cases of COVID-19 (and 345 deaths) in government-controlled areas since reporting began in March 2020, a recent Imperial College report (September 2020) estimated that only 1.25 percent of the COVID-19 deaths that have occurred in Damascus have been reported, making it likely the true number of total cases in Syria is significantly higher.[35], [36] COVID-19 poses a significant risk in areas outside of Damascus, including reconciled areas such as Daraa, where health professionals and facilities have little access to personal protective equipment, testing kits, and the means to monitor and treat severe cases. Furthermore, the pandemic has struck Syria at a particularly challenging time for the economy; sanctions imposed by the European Union and the United States have contributed greatly to the currency devaluation.[37] The weakened economy has impacted access to health care in Daraa, where government-provided services are inadequate, and patients must pay for transportation to functioning public facilities or seek care in the costly private sector.

This report provides insight into how Daraa’s health system has been affected by government recapture and demonstrates how the government is violating fundamental human rights to health and information, as well as humanitarian aid principles. Although access to health data in southern Syria is tightly controlled by the government, informed observers reported how local health authorities, in coordination with humanitarian actors, have responded to COVID-19. PHR researchers paid particular attention to the restriction of aid and human resources for health[38] for political purposes, as well as to threats to health care workers. Daraa’s struggling health system is the result of a decade of human rights abuses against the Syrian people by the government and its allies. The Syrian government’s intentional destruction of health facility infrastructure, targeted assassinations and kidnappings of health care workers, withholding of access to humanitarian aid,[39] and restrictions on data collection and dissemination have all contributed to the failure of the health system to meet basic population needs.

Methodology

The findings in this report are largely based on 19 key informant interviews conducted by Physicians for Human Rights (PHR) researchers between August and October 2020. The interviews were supplemented by a desk research review regarding COVID-19 and health system trends in Daraa and in southern Syria, more broadly.

Respondents interviewed by PHR included humanitarian workers, research analysts, academics, and journalists based in Jordan, Lebanon, Syria, Turkey, the United Kingdom, and the United States. A purposive sample of respondents was selected, based on their contacts inside Daraa, working knowledge of the health system in Daraa before and after reconciliation, and familiarity with COVID-19 in Daraa. The PHR research team developed a semi-structured interview guide in English, which was translated into Arabic. A native speaker of both Syrian Arabic and English conducted interviews remotely via Zoom in the language requested by respondents. Researchers obtained oral informed consent, and all personally identifiable information was de-identified using codes to maintain respondent confidentiality and safety.[40] This study underwent review and was approved by PHR’s Ethics Review Board.

The team conducted interviews until thematic saturation was achieved. Primary data were transcribed and analyzed to extract key themes relating to potential violations of the right to health[41] in Daraa. Two members of the research team participated in the majority of the interviews. One conducted the interview while the other transcribed. Recordings were used as reference to ensure completeness of the original transcription. In rare cases where only one team member was interviewing, the recording was used for the full transcription. Additionally, PHR’s research team consulted surveys of current gaps conducted in September 2020 in Daraa by the Syrian Center for Media and Freedom of Expression via its Violation Documentation Center in Syria; four such surveys contained data relevant to this report.

This study has six main limitations. First, there was no publicly available and independently monitored data about the health system and health needs in Daraa (and generally in areas retaken by the government). This lack constrained the team’s ability to determine the extent of access and quality of health services to meet population needs. Second, respondents based in Syria faced security risks, which may have affected their willingness to speak openly with PHR and share information. Only one interview was conducted with a health care worker based in southern Syria due to security concerns. Third, the remote nature of the interviews may have constrained the amount of information shared about this politically sensitive topic. Fourth, while the data illustrates how informed observers view the situation, some findings may not be generalizable due to sample size and limited perspectives from inside Syria. Fifth, while the team sought to use multiple sources of data and cross-check accounts among those interviewed, it was impossible to independently verify some interviewee accounts. Finally, Daraa’s security situation remains volatile, and the COVID-19 outbreak continues to evolve rapidly across Syria. Therefore, this information should be considered a snapshot of Daraa’s current health care situation and may not be predictive of what will occur in the coming months.

Findings

Daraa’s Health System: A Cautionary Tale

Between 2012 and 2018, Daraa’s health system had an active, NGO-led health sector.[42] By 2014, the Health Directorate established in opposition-controlled Daraa engaged in local health system governance;[43] it helped coordinate aid and services, including in the divided capital, Daraa City.[44] While Daraa City was under both government and opposition control, there was limited cross-line[45] collaboration between officials at the opposition and government-controlled Health Directorates on work such as vaccination campaigns.[46]

“The regime wants to eliminate the memory of the opposition and any sign of things that came before.”

Syrian doctor active in the south before reconciliation

From 2012-2018, international donors provided opposition-controlled Daraa millions of dollars in humanitarian aid across the Jordanian border. NGOs, operating through the Amman-based Health Cluster,[47] supported health facilities with financial and in-kind assistance, including human resources, medications, and supplies. Dozens of international NGOs directly implemented programs or remotely supported Syrian NGOs running health facilities.[48] Free health services provided by humanitarian-supported facilities replaced the public services that most citizens of Daraa had relied on before the war. With the support of international donors, even clinics in some small towns had advanced medical equipment during this period.[49]

By 2014, an estimated 3,500 doctors had fled Daraa, leaving behind only 20 percent of the original doctor workforce.[50] Physicians for Human Rights’ (PHR) research indicates that hospitals in Daraa were deliberate targets of aerial attack by the Syrian government and its Russian ally as early as 2015, with a notable increase in attacks in June 2018.[51] In comparison to other parts of Syria, Daraa has lost the most hospital beds since the conflict began: as of 2019, only 38 percent of beds were available due to damage to the national hospitals in Jassem, Nawa, and Daraa City.[52] Daraa’s health system suffered from repeated attacks on its facilities and personnel throughout the years of conflict. The systematic attacks, which were a crucial component of a wider strategy of war employed by the Syrian government and its allies, were particularly heightened during the fighting in 2018, which resulted in the retaking of Daraa and the start of the reconciliation period. [53]

Mseifra Hospital in Daraa after being attacked during an escalation of air strikes in June 2018. In comparison to other parts of Syria, Daraa has lost the most hospital beds since the conflict began: as of 2019, only 38 percent of beds were available, due to damage to the national hospitals in Jassem, Nawa, and Daraa City. Photo: Ammar Al Ali/Anadolu Agency/Getty Images

Reconciliation: Promises Unfulfilled        

The Syrian government reclaimed Daraa through a series of battles that ended in multiple negotiated surrender settlements with local fighters, which the government terms reconciliation agreements.[54] In June 2016, Syrian President Bashar al-Assad had signed Legislative Decree 15, later extended in Decree 23, which provided the national legal basis for reconciliation agreements by allowing amnesty for armed opposition members in return for “turning themselves in and laying down arms.”[55]

On May 4, 2017, the Islamic Republic of Iran, the Russian Federation, and the Republic of Turkey – guarantors of a putative ceasefire in Syria – signed a memorandum outlining the creation of “de-escalation areas,” the political framework in which the first campaigns to reconcile opposition-held territory took place.[56] The May 4 memorandum provided in relevant part that “rapid, safe and unhindered humanitarian access shall be provided”; “conditions to deliver medical aid to local population and to meet basic needs of civilians shall be created”; and “measures to restore basic infrastructure facilities, starting with water supply and electricity distribution networks, shall be taken.”[57] In July 2017, Jordan, Russia, and the United States separately negotiated the unpublished terms of a southern de-escalation zone, including Daraa and al-Quneitra in southern Syria.[58]

The reconciliation of Daraa was the result of a piecemeal approach in which a diversity of opposition leaders entered into separate local reconciliation agreements. The terms of agreements that ended the 2018 campaign to retake Daraa are contained in the July 1 and July 6, 2018 Busra al-Sham agreements,[59] and local agreements in other parts of Daraa reportedly used similar terms.[60] Some opposition leaders took advantage of the clause that those who did not want to go through the reconciliation process could “exit with their families to Idlib” (July 6, 2018 Agreement), although, reportedly, many remained due to their connection to their land and tribe. A humanitarian coordinator who used to oversee health activities in southern Syria explained that Daraa’s people are “connected to their land and would rather die there” than leave.[61]

In addition to referring to truces with local armed factions, the government of Syria also uses the term reconciliation to refer to the individual negotiated surrenders in which armed opposition members and civilians receive amnesty. This process involves interrogation by the intelligence services and swearing an oath of loyalty to the regime; in exchange, people theoretically receive a “security approval” card as confirmation of their reconciliation or settlement (taswiya) with the government.[62] People who had worked for health organizations during the period of opposition control were subject to these individual reconciliation agreements, whereby in exchange for information about colleagues and NGO activity, individual health care workers could receive the security approval necessary both for their safety and movement within and outside of Daraa and for any future work in the government health system.

The impact of reconciliation on the health system in Daraa illustrates the potential long-term effects on the right to health for populations in other areas that have also been retaken by the government.

Reconciliation agreement language that implied the health system would be maintained includes provisions to “work on the return of all employees to their government jobs” (July 1, 2018 Busra al-Sham agreement) and the assertion that “state institutions shall return to carry out their work in these cities and towns” (July 6, 2018 Busra al-Sham agreement). Before the war, the public sector was critical to the health system.[63] Respondents noted that, as part of the agreements, the government reportedly agreed to reinstate all dismissed government employees, including former Ministry of Health employees, and rebuild civil government institutions such as the public health sector.[64] One respondent, a Syrian security and humanitarian analyst based in Amman, reported that neither action has occurred two years after negotiation.[65] Thirty physicians who were former civil servants have been dismissed from their positions since reconciliation.[66] Much of the destruction caused by the fighting remains unrepaired since the government regained control of Daraa; as of October 2020, the government had not opened any new medical centers in the region since reconciliation.[67] Far from guaranteeing the protection and care of the local population, the reconciliation process was described by a Syrian civil society organization based in Amman as an “entrapment scheme that presented certain quite favorable terms to the population to encourage their surrender and then took these away.”[68] While each opposition-held territory in Syria is distinct, the impact of reconciliation on the health system in Daraa illustrates the potential long-term effects on the right to health for populations in other areas that have also been retaken by the government. 

After reconciliation, the government suspended cross-border humanitarian activities benefitting at least 568,000 civilians and triggered the withdrawal of national and international NGOs.

A man riding a motorcycle past destroyed buildings in the Syrian city of Daraa in August 2018. Much of the destruction caused by the fighting remains unrepaired since the government regained control of Daraa. Photo: Mohamad Abazeed/AFP/Getty Images

Humanitarian Health Activities Interrupted

After reconciliation, the government suspended cross-border humanitarian activities benefitting at least 568,000 civilians[69] and triggered the withdrawal of national and international NGOs present in Daraa since 2012.[70] Despite efforts by the UN Office of Coordination of Humanitarian Affairs (UNOCHA) to convince the parties to include provisions for humanitarian worker protections, these were not included in the reconciliation agreements, and no transition plan was enacted.[71] International and local humanitarian actors left Daraa on short notice, with many national staff hiding from Syrian security forces.[72] Because they had not registered in Damascus, all NGO and opposition-supported health facilities were considered by the government to be “illegal entities, according to an Amman-based human rights researcher.[73] Therefore, even the infrastructure supplied and maintained by NGOs, such as electricity generators and water and sanitation equipment, was dismantled. Leading up to this period, civilians relied on NGOs to support the health system in Daraa. A Syrian physician working with a humanitarian organization in Syria explained, “The regime wants to eliminate the memory of the opposition and any sign of things that came before.”[74] This policy has resulted in the destruction of the opposition-era health system and the concentration of health care services in urban centers, creating barriers to access for those in rural areas, which are made worse by the cost and danger of travel posed by looters on the road and by the government at security checkpoints.

Health Care Worker Shortage

Requirements that health care providers undergo reconciliation processes exacerbated the shortages of health care workers that are a major impediment to civilian health care access. Significant displacements occurred in Daraa during the uptick in hostilities in 2018, and likely included qualified health care providers who worked for humanitarian aid organizations, who were particularly fearful of violence and retribution from government security forces during the reconciliation process.[75] Those who had worked with NGOs or in opposition-controlled facilities had to “surrender themselves to authorities and be subject to interrogation and confession.”[76] Individual health care workers were technically allowed to return to work after undergoing these individual reconciliation agreements and being “cleared” by the security forces. In practice, many were reportedly denied clearance.[77] Despite the clear need for health care workers, many of those granted authorization reported difficulty finding public sector employment. Some who found employment have continued to be targeted by violence, including health care workers who went through individual reconciliation processes with the government and those who had treated fighters and were “specifically targeted as they left their clinics.”[78] Others were reportedly arrested even after the reconciliation process.[79], [80]

Health care providers who had worked with NGOs or in opposition-controlled facilities had to “surrender themselves to authorities and be subject to interrogation and confession.”

Respondents described the lack of qualified health providers as the biggest challenge to Daraa’s health system. COVID-19 will likely continue to drive this number down, as providers become ill and die after exposure or are too scared to practice without appropriate personal protective equipment (PPE). The table below demonstrates that, in 2019, the number of providers per unit population in public hospitals in Daraa is dramatically lower than in the loyalist areas of Damascus, Latakia, and Tartous.[81]

Table 1. The number of health care workers (doctors, nurses, and midwives) at public hospitals per 10,000 in population, by governorate.[82]
Governorate# of Midwives   # of Nurses# of Medical Doctors*
Damascus0.920.520.3
Daraa0.54.11.1
Latakia2.121.515.3
Tartous1.325.812.9
*Includes general practitioners, specialists, emergency physicians, resident doctors, and dentists.

In 2019, the number of doctors per 10,000 residents in Daraa was 1.1, while in Damascus, it was 20.3. Of the eight “national” or public hospitals in Daraa, only one is fully functioning.

A Syrian man receives treatment in an underground hospital in Daraa in April 2018. Requirements that health care providers undergo reconciliation processes after the government takeover exacerbated the shortages of health care workers that are a major impediment to civilian health care access in Daraa.
Photo: Mohamad Abazeed/AFP/Getty Images

Despite respondents’ reports of health care workers unable to find public sector employment in Daraa, the Ministry of Health has reportedly struggled to find a qualified health care workforce.[83] Reports indicate there are no psychiatrists, and those acting as mental health providers have not received proper clinical training.[84] Specialists such as endocrinologists, surgeons, or even gynecologists are in short supply. Nurses and midwives generally provide all reproductive and maternity health care. Medical residents and students have reportedly been hired as general practitioners before their training is complete, calling into question the quality of care they provide.[85] A few Ministry of Health providers rotate between public facilities outside of Daraa City, where limited services are available. [86] 

Of the eight “national” or public hospitals in Daraa, only one, in Daraa City, is defined by the World Health Organization (WHO) as fully functioning. PHR has documented a total of 30 attacks on health facilities in the Daraa governorate attributable to the Syrian government or Russian forces since 2011, and a total of six attacks on health care during the military takeover in June 2018.[87], [88] One public hospital, al-Hirak, no longer functions, due to damage sustained during the conflict. Six public hospitals are “partially functioning,” due to physical damage, which seriously limits the services provided.[89] For example, despite rehabilitation and equipment investments, Jassem National Hospital functions as little more than a medication dispensary, due to the small number of physicians.[90] Nawa National Hospital is reportedly limited mainly to labor and delivery services and radiology, and Tafas National Hospital can only treat basic cases.[91] There are no specialized clinics inside most hospitals, forcing community members to pay for private care or travel to Daraa City.[92]

COVID-19: Acceleration of the Health Crisis in Daraa

Cases of COVID-19 were first reported by the Syrian government on March 22, 2020. These early cases were likely due to a wave of religious pilgrims from Iran visiting Syria in late February, ongoing movement of militia fighters, and Syrian students returning from Wuhan, China, where COVID-19 cases first emerged.[93]Although reliable health data is extremely limited, credible reports indicate that COVID-19 continues to spread at an alarming rate across Syria, which observers describe as “woefully unprepared” for pandemic response.[94] Interviewees indicated that the Syrian government is doing little to contain the spread of COVID-19, particularly in Daraa.[95] A humanitarian worker based in Amman who oversees health programming in southern Syria noted, “I don’t know that we’ll ever know the true scale of it. The toll has got to be in the tens of thousands, if not higher. Every bed is full.”[96]

COVID-19 continues to spread at an alarming rate across Syria…. Interviewees indicated that the Syrian government is doing little to contain the spread, particularly in Daraa.

Early in the pandemic, the Syrian Ministry of Health began implementing triage measures in hospitals, selecting only patients demonstrating severe COVID-19 symptoms for further testing or treatment and requiring all others to quarantine themselves at home. Throughout government-controlled areas, public hospitals have reportedly enforced limitations on the number of days a patient can stay per week. Some patients choose to pay a bribe to the hospital administration to stay longer.[97]

According to multiple sources, there are about four quarantine or isolation centers in Daraa, which receive referrals from hospitals, primary health care providers, and security forces who conduct contact tracing.[98] Reportedly, conditions in these centers are deplorable, crowded, and unsanitary, with reports of people paying bribes to leave without completing the full quarantine period enforced by local authorities.[99] There are also reports of people fearing arrest or poor treatment in government-run quarantine centers, leading many in Daraa to self-quarantine or isolate at home rather than seek treatment.[100]

Health care facilities damaged during the fighting, along with a lack of supplies and health care providers, have hindered COVID-19 response efforts in Daraa. Daraa has experienced shortages of PPE, ventilators, and health care workers, limited testing capacity, challenges to drug procurement, and limited support for public hospitals.[101] While there is conflicting and scarce data regarding the number of intensive care unit beds with ventilators,[102] even the highest estimate of 31 is insufficient to treat a population last officially reported as 680,404.[103] Respondents noted a lack of ventilators in Daraa, and the relative availability of ventilation machines in areas considered loyal to the Syrian government.[104]

In the absence of government policies or significant humanitarian response, communities have attempted to address these service shortages through financial support to local hospitals and community awareness campaigns.[105] As a Syrian civil society organization described, the “burden has been shifted on the community to react to the virus.”[106] Busra al-Sham Hospital, one of the national hospitals in Daraa, held a grassroots fundraiser and raised $160,000 to procure medications, improve water quality for the area, and establish an isolation center in a nearby school.[107] Other examples provided by an interviewee included crowdsourcing in Tafas among local mosques and community leaders to increase COVID-19 health supplies in Daraa.[108] According to an American think tank report in October 2020, however, efforts to raise money and collect supplies are being closely monitored by security forces, with some instances of interference.[109]

“In comparison to other parts of Syria, Daraa is a black hole from the medical perspective; not much information is available regarding COVID-19.” [110]

U.S.-based Syrian medical doctor

As with most secondary health services since reconciliation, severe COVID-19 cases in Daraa require transfer to Damascus. Outpatient services across the Daraa governorate have reportedly been suspended, as have elective surgeries,[111] depriving people with chronic conditions of adequate care. In light of the lack of fully functioning health facilities, a surge in COVID-19 cases would mean few local health care options. As discussed in detail in Section E below, several interviewees reported instances where people tried but failed to access Damascus’s health services due to the prohibitive cost of transportation and treatment, danger at checkpoints, and a lack of capacity to admit patients with COVID-19 symptoms even in the capital. Several interviewees mentioned that the situation created by COVID-19, while serious, was not as significant as the pattern of health service discrimination overall in southern Syria.[112] A U.S.-based researcher explained that it is not “smart to compartmentalize COVID-19 as the reason why there is little access to health services, because there isn’t access to services in general. When you look at these areas, there has been a considerable downfall of services since reconciliation.”[113]

Daraa: A “Black Hole” of Data

There are credible reports that, in the first months of the COVID-19 crisis, the Ministry of Health worked with the intelligence services, or mukhabarat, to intimidate and detain both providers and patients across the country to suppress data collection and dissemination about COVID-19. Initially, the government tried to deny cases were occurring.[114] A Syrian researcher noted that “at the beginning, the mukhabarat really didn’t want the news of the number of cases to get out.”[115] He reported credible allegations that in the early months of the pandemic, security forces were in COVID-19 wards to monitor information shared by doctors and their patients; they also conducted contact tracing and patient monitoring.[116] A human rights researcher reported being told that the Ministry of Health releases information about new cases of COVID-19 to the WHO only after review by the Syrian Arab News Agency and government security forces.[117]

In addition to the suppression of data collection and dissemination by government security services, government restrictions on NGO monitoring of health activities, lack of data coming from the WHO, and insufficient testing capacity to inform Ministry of Health surveillance reports limit available information regarding COVID-19 in Daraa. Very little health information on the facility level is available directly to NGOs, rendering them dependent on the WHO and the Ministry of Health for morbidity data that could otherwise shed light on COVID-19 prevalence in the southern region.[118] The WHO’s Early Warning Alert and Response System (EWARS) is supposed to provide timely disease surveillance data for Syria. In a notable failure of this surveillance system, no EWARS report for government-controlled areas of Syria has been issued since early March 2020, before the Syrian government acknowledged any cases of COVID-19 within its borders.[119] Based on available information, the UN Humanitarian Needs Assessment Programme determined as of November 2020 that access to COVID-19 health services – such as testing provisions for COVID-19, quarantine spaces for diagnosed cases, isolation space in health centers for suspected cases, and provision of space in health facilities to monitor suspected cases – is insufficient across most of the Daraa governorate.[120], [121]

The Ministry of Health worked with the intelligence services to intimidate and detain both providers and patients across the country to suppress data collection and dissemination about COVID-19.

 Limited COVID-19 Testing and Processing

Although in September 2020, UNOCHA reported the government’s stated commitment to establish COVID-19 testing laboratories “in all 14 governorates,” including Daraa,[122] testing remains severely limited outside areas deemed loyal by the government. Disparities in access to testing have led to visibility of only severe cases of COVID-19 in Daraa and other parts of Syria, with one researcher claiming that up to 90 percent of cases in Syria are not diagnosed.[123] Even the Syrian Ministry of Health has, as one security analyst based in Amman explained, “hinted that their numbers might be inaccurate, realizing that there are not enough of PCR [polymerase chain reaction] tests in the country.”[124] According to the Humanitarian Needs Assessment Programme, no sub-districts in Daraa currently have testing provisions for COVID-19.[125]

In areas under Syrian government control, including Daraa, samples are reportedly collected and sent to Damascus for confirmed PCR lab testing. Interviewees indicated that Daraa National Hospital has the capacity to collect and store COVID-19 samples; however, processing of all laboratory testing is conducted in Damascus. A health care worker from Daraa noted major delays in receiving test results from Damascus, indicating their personal COVID-19 test result took nine days.[126] A related difficulty includes the physical transfer of samples from a lab in Daraa to Damascus’ central lab, which requires wasta, or power and connections. Alternatively, a patient can pay what a respondent called “a lot of money” for a specialized team to ship their sample safely and receive quick test results.[127]

Reportedly, tests have been reserved only for patients with severe symptoms and are provided after they receive abnormal chest X-ray results. Chest X-rays are in high demand and require a long wait.[128] Observers noted civilians are being charged more than $200 for COVID-19 tests.[129] A journalist who covers COVID-19 in Syria speculated, “Is it conceivable that people are having to pay for donated tests? The WHO has provided tests, Russia and China have also provided tests. Businessmen have tried to import tests, but they have been blocked, not by the sanctions, but blocked by the bureaucracy.”[130] If true, the above allegations could indicate the government’s intent to prevent access to testing materials, while diverting blame from itself and onto the sanctions for increasing prices of medical supplies and aid.[131]

Suppression of Information

While the grave economic and health impacts of the pandemic on the population are clear, physicians and prominent government officials who expressed concern about the spread of COVID-19 have received warnings or reprisals from the government.[132], [133] A security analyst based in Amman indicated that those who make public statements that run contrary to the Ministry of Health are likely “to get arrested by Syrian intelligence agencies,” resulting in “huge fear among health workers” of discussing COVID-19 with anyone.[134] A respondent related the story of a health care worker known to him in Syria who identified an early COVID-19 case.[135] After the health care worker alerted officials that he had a case with all the relevant symptoms, government security forces quickly arrived at the hospital. He was told not to send any more cases of COVID-19 to Damascus and to report future cases to the security forces so that they could “decide whether or not to transfer the case to Damascus.”

Active suppression of information by government security services about COVID-19 transmission makes it impossible to track the epidemic in Daraa, and for the population to understand how to assess risk in conducting daily activities. Daraa is largely rural, with only a few larger cities, with less risk of high COVID-19 transmission due to population density.[136] However, the Nasib border crossing between Syria and Jordan is one of only two for significant transportation of goods, and no COVID-19 screening measures were implemented there between March 2020 and mid-August 2020, while COVID-19 was spreading through Syria.[137] A respondent expressed concern that “Jordan is reporting high rates from Syria, and anyone who goes to Jordan has to pass through Daraa,” indicating potential implications for Jordan should COVID-19 cases increase significantly along the southern Syrian border.[138]

“[Syria] has lost 60, maybe 100 doctors…. I don’t understand why human capital is not the absolute priority. Save the doctors, at least.”

Journalist who researched COVID-19 in Syria
Syrian Arab Red Crescent (SARC) trucks carry humanitarian aid into Daraa in July 2018. Since the recapture of Daraa, the Syrian government has largely obstructed the delivery of humanitarian aid there; when aid does reach Daraa, according to one respondent, SARC directs it to areas more firmly under government control, withholding aid from areas that remain “opposition-minded.” Photo: Mohamad Abazeed/AFP/Getty Images

COVID-19 and Humanitarian Aid

COVID-19 interrupted humanitarian aid activity throughout Syria, forcing international staff to leave the country and suspend projects.[139] Interviewees noted that Syrian Arab Red Crescent (SARC) activities have not been significantly scaled up in response to COVID-19 in Daraa. Instead, its services have largely been limited to the distribution of soap and periodic transfers of patients to hospitals in Damascus.[140] In Daraa, unregistered local civil society organizations that receive support from informal community and diaspora networks have tried, and in some cases succeeded, to improve health system capacity to address COVID-19 in the absence of government or humanitarian aid.[141]

The preferential distribution of aid has intensified health care inequality during the COVID-19 response effort in Syria. The WHO reportedly distributed 4.4 million PPE items across government-controlled areas; however, health care workers, particularly in rural parts of the country like Daraa, experienced significant shortages.[142] A human rights researcher based in Amman noted that “There does not seem to be a strategy or desire from the Ministry of Health to respond in an equitable manner,” particularly in addressing shortages in PPE, drug procurement, and support to public hospitals in Daraa.[143] Qualified health care workers – already in short supply across Syria – have been exposed to COVID-19. In late September 2020, a list of 61 doctors in Syria who reportedly died from COVID-19 was shared on Facebook by fellow Syrian health care workers.[144] A journalist who researched COVID-19 in Syria emphasized the impact on doctors and nurses of the ineffective distribution of WHO aid: “WHO is saying they have access, but where is WHO in the COVID-19 wards?… [Syria] has lost 60, maybe 100 doctors. Syria cannot afford to lose 100 doctors…. I don’t understand why human capital is not the absolute priority. Save the doctors, at least.”[145]

Humanitarian access to Daraa has reportedly only become more challenging since the first reported COVID-19 case in Syria. Travel between Syria’s governorates was not allowed between March 23 and May 25, 2020,[146] and Damascus-based NGOs are hesitant for staff to travel to Daraa due to the COVID-19 and security situations.[147] Despite these challenges, in the fall of 2019, before the COVID-19 outbreak, UNOCHA solicited proposals for programming in southern Syria, which would allow Daraa to receive funding for health and other humanitarian activities.[148], [149] However, humanitarian workers reported that little has been done in terms of implementation of new activities since then, as increased vetting and bureaucratic procedures and regulation by the Ministry of Health have led most international NGOs to scale back their services significantly in Daraa or divert their programming to the SARC.[150] For example, the WHO has attempted to negotiate with the government to expand COVID-19 testing capacities but has not shared these details or challenges publicly.[151] 

“The government has kept UN and humanitarian actors very far away from southern Syria. It is a deliberate attempt to distance us. The South is being treated as enemy territory.”

Humanitarian worker

Government Restrictions on Humanitarian Access, Monitoring, and Aid Distribution

Throughout the conflict, the Syrian government has restricted both humanitarian access and aid, in violation of international humanitarian law and humanitarian principles.[152] Observers indicate this practice has continued in territories retaken by the government by limiting permissions for NGO registration and access,[153] taking excessively long to approve projects, and restricting monitoring visits.[154] A human rights researcher noted, In terms of service provision, it is problematic because you don’t know where the needs actually are.[155]  The Syrian government heavily regulates the handful of UN agencies and international NGOs who continue to support health programs in the south.[156] Some international organizations have continued to operate quietly or remotely in the south, but struggle to secure the required registration in Damascus. Rather than direct service delivery, their projects are often small-scale or limited to infrastructure rehabilitation.[157] SARC technically provides limited free health services in Daraa;[158] however, interviewees indicated that its activities since 2018 have been insufficient to meet population needs.[159]

The government granted approval to a small number of international and local organizations that had been operational in Damascus prior to reconciliation, including humanitarian agencies affiliated with Russia and selected faith-based organizations. SARC is tasked with providing health services in government-controlled areas and is authorized to coordinate local NGO activities, including NGOs that the government considers pro-regime.[160] Operational organizations in Daraa rely on government permissions for all aspects of their work, including local partner selection and permits for monitoring visits, and travel is highly restricted. A humanitarian worker explained, The government has kept UN and humanitarian actors very far away from southern Syria. It is a deliberate attempt to distance us. The south is being treated as enemy territory.”[161]

Respondents indicated that the government routinely diverts aid by releasing recipient lists to SARC only after security personnel have removed the families of people blacklisted by the regime.[162] A Syrian researcher specializing in Daraa noted this practice has resulted in aid for women-headed families of deceased combatants being restricted to those who “lost fighters on the regime side,” and indicated that wasta – personal connections – further skews distribution of aid.[163] He noted that while people suspected of past opposition activity are removed from the aid distribution list, “family members of the military, members of the Baath party, and mukhabarat [secret police]” benefit from the aid.

Civil society organizations reported concerns that the Syrian government “selectively supplies humanitarian provision to areas to reward them for support,” and expressed concern that the government was misdirecting aid.[164] A respondent reported that even when aid reaches Daraa, SARC has directed aid to areas within the governorate more firmly under government control, withholding aid from areas that remained “opposition-minded.”[165]

Poverty, Security, and Health Care Access

“Bashar al-Assad said people are either going to die of hunger or corona [virus].” [166]

Humanitarian worker in northwest Syria

Syria’s economy, depleted by years of conflict and destruction, is further suffering from international sanctions,[167] financial instability in neighboring Lebanon, and a global economic crisis, creating conditions in Daraa in which medication and health care services are largely unaffordable.[168] Daraa has long been one of the poorest governorates in Syria,[169] and its economy has worsened since reconciliation, with multiple gas and electricity shortages.[170] Health access disparities in Daraa were deepened by the lack of public health infrastructure development in the period following reconciliation.[171] A single prescription might cost $20-25, half of an average monthly salary, and prices are predicted to rise.[172] Specialist care requires a trip to Damascus, but private transportation to such facilities is expensive and beyond the budget of most families. Only patients with financial resources and connections may be able to access adequate facilities with medications and supplies in Daraa City or Busra al-Sham, the major cities in the area.[173]

Respondents noted a strong correlation between poverty and lack of health care access throughout Syria, which has increased with COVID-19.[174] In order to receive COVID-19 care, patients have had to pay bribes for hospital admission, as well as for their own oxygen supplies. COVID-19 patients treated at home must pay for nursing care, as well as for PPE and oxygen, which are already scarce.[175] Reportedly, patients without COVID-19 symptoms choose to pay for treatment at private hospitals because they fear exposure to the virus at the crowded and unsanitary public facilities.[176] Access to care may further depend on connections to armed groups, whose influence extends to hospitals.[177]

In order to receive COVID-19 care, patients have had to pay bribes for hospital admission, as well as for their own oxygen supplies.

Since reconciliation, physical insecurity for civilians has continued to expand, with increasing reports of targeted assassinations,[178] kidnappings, robberies, and overall volatility in Daraa.[179] According to a humanitarian worker operating in southern Syria, opportunistic violence in Daraa has increased, and health facilities have been looted. [180] In February 2020, two Syrian Oxfam aid workers were targeted and killed in their vehicles by unidentified gunmen.[181] Civilians have been stopped and harassed at government checkpoints, and experts predict the security situation in Daraa will continue to impact access to essential services, including health care.[182]

Security checkpoints have increased in the COVID-19 era. Young men may be apprehended at a checkpoint because their “reconciliation card” may not be accepted, they are wanted by the government for opposition involvement, or they have not completed the compulsory military service.[183] Staff of a Syria-focused human rights organization noted, “A lot of people in need of health services have to go to Damascus. But half of Daraa’s young men would be arrested.”[184]

Even patients who do not have to pass through checkpoints may face security risks if admitted to public hospitals. At Daraa National Hospital, detentions have been reported. For example, a male patient without proof of military service may have a credible fear of being arrested – while an inpatient – for having avoided conscription.[185] A security analyst based in Jordan explained, however, that security services “are not present in private hospitals,” worsening disparities in access to health services between those who can and cannot afford private care.[186]

A vehicle labeled “Health Center in Daraa City.” Government-caused destruction and neglect have made Daraa’s health system undersupplied, understaffed, and incapable of providing basic services, let alone handling a widespread COVID-19 outbreak. Photo: Courtesy of Syria Direct

Legal and Policy Implications

“The support only goes to the areas and individuals the regime wants.” [187]

Syrian researcher based in Turkey

The civilian population of southern Syria has experienced a drastic rupture in its health system due to policies enacted after reconciliation that restrict information, goods, and services. With many parts of the formerly opposition-held territory now retaken by the government, a new set of concerns has emerged alongside the targeting of medical professionals and facilities: the arbitrary withholding of aid, diversion of humanitarian assistance, and restriction of data collection and distribution of information. This disturbing pattern represents a new challenge for humanitarian actors and human rights observers. In addition to state crimes of violence against medical personnel and infrastructure, the Syrian government has violated civilians’ right to health, diverted and withheld humanitarian assistance to vulnerable civilian populations, and actively suppressed the right to information in a pandemic.

Right to Health

Physicians for Human Rights (PHR) has long documented violations of international humanitarian and human rights law in Syria, including Common Article 3 of the Geneva Conventions and its Additional Protocols, which prohibit the targeting of those providing and receiving medical care.[188] No less important is the right to health, articulated in Article 22.2 of the 2012 Syrian Constitution. It provides that “The state shall protect the health of citizens and provide them with the means of prevention, treatment and medication.”[189] The right to health is further enshrined in Article 12 of the International Covenant on Economic, Social and Cultural Rights, to which Syria is a party.[190] The government systematically destroyed health care infrastructure in Daraa and targeted health care workers prior to reconciliation. Since 2018, the government has restricted humanitarian assistance and supplies designated for Daraa. The health system is understaffed to the point of denying access to care. By destroying the health care system and then allowing it to fail since 2018, the Syrian government has effectively deprived Daraa’s citizens of their right to health.

By destroying the health care system and then allowing it to fail since 2018, the Syrian government has effectively deprived Daraa’s citizens of their right to health.

Norms for Provision of Humanitarian Assistance

The Syrian government has had an established pattern of diverting aid, including medical supplies, as a weapon of war throughout the Syrian conflict, a tactic which it continues to use in recent months, including in areas that have been reconciled .[191], [192] A respondent observed that “the support only goes to the areas and individuals the regime wants.”[193] United Nations Resolution 2254 (2015) urges all parties to allow humanitarian agencies “rapid, safe and unhindered access throughout Syria by most direct routes, [and to] allow immediate, humanitarian assistance to reach all people in need, in particular in all besieged and hard-to-reach areas.”[194] The government has restricted access to reconciled areas like Daraa, preventing monitoring as well as aid distribution. Accountability for diversion of aid distribution and for the arbitrary withholding of such aid from civilian populations, including in Daraa, is critical for improving civilian health outcomes. 

PHR recognizes that multilateral institutions and NGOs must navigate a complex legal environment in areas where, as in Daraa, the government has retaken territory but is unable or unwilling to provide the requisite assistance to civilians. These difficulties do not relieve their duty to provide assistance in line with humanitarian principles, and to promote the right to health for populations in areas where health systems appear close to collapse.

Surveillance and dissemination of public health information has never been more critical than during the COVID-19 pandemic. The right to information derives from Article 19(2) of the International Covenant on Civil and Political Rights, which articulates the right to “seek, receive and impart information,”[195] and to which Syria is a party. The COVID-19 health emergency creates a positive obligation on states to provide citizens with reliable information about health risks, disease spread, and preventive measures, since this information is linked to both the right to life[196] and the right to health.[197] The UN Committee on Economic, Social and Cultural Rights has called on states to provide “access to information concerning the main health problems in the community, including methods of preventing and controlling them” as part of the core obligation to protect the right to health.[198] While the right to information during health emergencies is an emerging area of public international law, interest is likely to expand in reaction to the COVID-19 crisis. Article 5(c) of the Aarhus Convention on Access to Information, Public Participation in Decision-Making and Access to Justice in Environmental Matters states in relevant part that “In the event of any imminent threat to human health … all information which could enable the public to take measures to prevent or mitigate harm arising from the threat and is held by a public authority” should be disseminated immediately.[199] Although it is not yet binding customary international law – defined by the general and consistent practice of states following from a sense of legal obligation – the growing number of parties (25 percent of UN member states are parties, another 20 percent are signatories) indicates the significance of the link between the right to government information and the right to health.

The Syrian government has violated civilians’ right to health, diverted and withheld humanitarian assistance to vulnerable civilian populations, and actively suppressed the right to information in a pandemic.

While Daraa is relatively rural, its strategic location at the gateway to the Jordan border crossing means that it is exceptionally vulnerable to COVID-19 super spreader events, particularly due to the degradation of its health system since reconciliation. The Syrian government’s suppression of vital health information makes it impossible for its citizens to make informed choices to protect themselves and impacts people in other countries.

Conclusions

Through years of assault on medical infrastructure, the dismantling of humanitarian investment in the health system, underinvestment in health human resources, and unfulfilled promises made during the reconciliation process, the Syrian government has rendered Daraa’s health system extremely fragile. The country’s current economic and security crises have further complicated access to health care during the COVID-19 pandemic, making routine care difficult and COVID-19 care nearly impossible. Critically, the lack of independent data collection in Daraa and other reconciled areas, as well as the government’s suppression of information about the pandemic, means that neither population needs nor COVID-19 case counts are known.

The findings and analysis in this report demonstrate that the Syrian government has severely compromised the right to health of the population of Daraa through discrimination, neglect, failure to allow for humanitarian assistance, and suppression of vital information about the COVID-19 pandemic, on top of the crimes committed against health facilities and personnel during almost 10 years of conflict. Overt interference in humanitarian relief efforts and access to care for civilians, as well as government neglect of the Daraa health system, may presage what lies in store for other areas retaken by the government. Long-term implications of the overt neglect of health care service include severe and irreversible consequences of malnutrition, mismanagement of chronic diseases, and unaddressed mental health conditions. The current COVID-19 outbreak in Syria threatens civilian safety across the country, but particularly in reconciled areas with weakened health systems. COVID-19 has had a compounding effect on preexisting health disparities in former opposition-held areas like Daraa already impacted by a decade of conflict, a fragile economy, and the presence of armed actors limiting access to health care.

Humanitarian actors have faced significant moral and practical challenges to providing aid in Syria, with some organizations choosing to be based in Damascus and others working across the border in Turkey or Jordan. Each organization must operate according to its mandate, internal policies, and risk tolerance. However, given the credible allegations of large-scale violations of humanitarian norms and the right to health and the dangers of COVID-19 spread within and from areas without functional health systems, organizations present in Syria must push for greater access and information to protect the lives and livelihoods of affected populations in reconciled areas.[200] 

A human rights crisis lies at the origin of the humanitarian crisis in Syria. Government suppression of the right to expression and information, especially in a pandemic, is emblematic of the violent state practices that contributed to the protests which precipitated nearly 10 years of conflict. Accountability and change will be critical for a post-conflict Syria that upholds human rights, which is key to peace, stability, and development. 

Recommendations

Considering the profound and ongoing civilian suffering in Daraa, there are concrete steps the Syrian government, international community, humanitarian organizations, and donors can take to support access to health care in Syria and improve the country’s COVID-19 response equitably for all residents, without discrimination. The international aid community, including donor governments and NGOs, must engage in a human rights-based approach to monitoring, surveillance, and assistance in Syria, particularly in areas now under government control.

PHR calls on the concerned parties to take the following actions:

To the Syrian Arab Republic:

  • Lift barriers for reconciled health care workers seeking public sector employment;
  • Expand access for desperately needed humanitarian aid to areas retaken by the government, and those areas still held by the opposition;
  • Adopt transparent measures to prevent diversion of assistance and provide donors with accounts of aid distribution in reconciled areas, including COVID-19 testing and personal protective equipment distribution;
  • Verify that public sector services, as well as services provided by the Syrian Arab Red Crescent, are equitable and accessible to all civilians and not distributed based on discriminatory or preferential measures; and
  • Ensure that the Ministry of Health allows full access to World Health Organization (WHO) field workers deployed to assess the situation in Daraa.

PHR recognizes that the Syrian government’s longstanding persecution of health care workers continues with impunity and reiterates these recommendations to the government:

  • Stop intimidating, threatening, arresting, disappearing, torturing, and killing health care workers; and
  • Release all those arbitrarily detained or persecuted for carrying out their medical duties and exercising their basic human rights.

To the UN Security Council and UN Member States:

  • Demand monitoring of violations of the right to health in areas that have been retaken by the Syrian government;
  • Place pressure on the government to ensure the delivery of aid and allocation of health services so that organizations such as the WHO and other UN agencies, international NGOs, and local actors can reach populations in a neutral, effective, and equitable manner;
  • Call on Russia to stop assaulting health care facilities in violation of international humanitarian law and human rights law;
  • Insist on accountability for previous and ongoing violations of civilians’ right to health across Syria, particularly in areas retaken by the government; and
  • Demand the distribution of timely, detailed epidemiological information about the extent of the COVID-19 pandemic consistent with the right to information.

To Jordan, Turkey, and the United States, Guarantors of the Southern De-escalation Zone:

  • Exert pressure on Syria to include the health system in any negotiated settlements and facilitate humanitarian access by increasing security, travel permits, independent data collection, and publication of health system data.

To Humanitarian Actors and Implementing Organizations:

  • The WHO should release an updated Early Warning Alert and Response System report, to provide timely disease surveillance data for Syria with regional reporting, including on COVID-19; 
  • The WHO should urge ongoing and regular coordination with implementing health organizations to conduct data collection. UN agencies and NGOs with a presence in south Syria should scale up testing capacity, supplies, and medications based on this information about those most vulnerable;
  • Conduct independent needs assessments to ensure equitable service provision and inform coordination. Monitoring of medication and supplies will also provide local and international communities with information necessary to understand the health system’s preparedness in Daraa to respond to COVID-19 and other health needs;
  • To ensure the right to health in reconciled areas, the WHO and the international donor community should track the rebuilding and rehabilitation of facilities damaged by attacks since 2011;
  • Monitor government aid and data collection practices;
  • Ensure the right to access timely and transparent health information during a health emergency by pressuring the government to release relevant information;
  • International actors should promote health care worker protections, including through negotiations with the Syrian government. Providers should be guaranteed minimum standards of safety in hospitals to prevent further fatalities; and
  • Encourage international and local organizations to adopt COVID-19-friendly provider practices, including limiting house visits and using telemedicine and other remote health care initiatives, where internet access allows.

To Donors:

  • Actively press the WHO and international groups operating in Damascus to pressure the Syrian government to allow for decentralized testing and equitable distribution of protective equipment;
  • Monitor aid delivery and distribution carefully to avoid diversion and neglect of areas retaken by the government; and
  • Address indications that the Daraa health system is near collapse. In Daraa and in other areas retaken by the government, where the government is unable or unwilling to provide funding and resources for the most basic health services, humanitarian assistance should be extended.

Acknowledgments

This report was written by Justine McGowan, MSc and an anonymous author. Adrienne L. Fricke, JD, MA, senior research fellow, Harvard Humanitarian Initiative, and visiting scientist at the Harvard T.H. Chan School of Public Health, contributed to the research and writing.

Physicians for Human Rights (PHR) leadership and staff contributed to the writing and editing of this report, including DeDe Dunevant, director of communications; Michele Heisler, MD, MPA, medical director; Donna McKay, executive director; Karen Naimer, JD, LLM, MA, director of programs; Michael Payne, interim director of advocacy; and Susannah Sirkin, MEd, director of policy. Former PHR researchers Tamaryn Nelson, MPA and Rayan Koteiche, MA and former advocacy coordinator Lawrence Robinson, MA helped develop the research design and policy objectives.

The report benefited from review by PHR Board Member Emeritus Dr. Robert S. Lawrence, MD and by Dr. Samer Jabbour, MD, MPH, professor of public health practice, Faculty of Health Sciences, American University of Beirut, PHR Advisory Council. It was reviewed, edited, and prepared for publication by Claudia Rader, MS, senior communications manager, with assistance from Isa Berliner, communications intern, and Joseph Leone, research and investigations fellow. An anonymous MENA intern also contributed research. Hannah Dunphy, MA, digital communications manager, prepared the digital presentation.

PHR would also like to thank the Syrian Center for Media and Freedom of Expression for the data they shared from the Violations Documentation Center in Syria. PHR is grateful to Ali Barazi and his associates for translation services. PHR is especially indebted to all of the people inside and outside of Syria who agreed to be interviewed. 


Endnotes

[1] In this paper, Daraa refers to the governorate of Daraa, Syria. Daraa City will be used to refer to the capital city of the same name.

[2] Suleiman al-Khalidi, “Numbers of displaced in southern Syria climbs to 270,000: U.N.,” Reuters, July 2, 2018, https://www.reuters.com/article/us-mideast-crisis-syria-un-displaced-idUSKBN1JS11T.

[3] Fouad M. Fouad et al., “Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria,” The Lancet 390, 10111, (December 2018),   https://www.sciencedirect.com/science/article/abs/pii/S0140673617307419

[4] The terms “reconciliation” and “reconciled areas” are controversial in the Syrian context. Many interviewees stated that the process by which the government retook Daraa and its subsequent failure to fulfill its promises to return critical services to the area cannot be described as a true reconciliation in which both sides are implied to have recognized rights. Within the academic literature, scholars of the Syrian conflict use the term without quotation marks after noting that it euphemistically refers to local surrender agreements between the government and opposition forces in areas retaken by force. PHR follows academic convention in the use of the term without quotation marks but does not endorse the legitimacy of these agreements.

[5] Armenak Tokmajyan, “How Southern Syria Has Been Transformed Into a Regional Powder Keg,” Carnegie Middle East Center, July 14, 2020, https://carnegie-mec.org/2020/07/14/how-southern-syria-has-been-transformed-into-regional-powder-keg-pub-82202.

[6] World Health Organization, “HeRAMS Annual Report (January – December 2019): Public Hospitals in the Syria Arab Republic,” 2020, https://apps.who.int/iris/bitstream/handle/10665/333184/WHOEMSYR039E-eng.pdf?sequence=1&isAllowed=y.

[7] Interviews with JO07 on September 15, 2020 and JO08 on October 14, 2020.

[8] United Nations Office for the Coordination of Humanitarian Affairs, “Syrian Arab Republic: Humanitarian Needs Overview,” accessed November, 12, 2020, https://data.humdata.org/dataset/syrian-arab-republic-humanitarian-needs-overview.

[9] World Health Organization, “Syrian Arab Republic: WHO Coronavirus Disease (COVID-19) Dashboard,” accessed December 1, 2020, https://covid19.who.int/region/emro/country/sy.

[10] Oliver J. Watson, et al., “Estimating the burden of COVID-19 in Damascus, Syria: an analysis of novel data sources to infer mortality under-ascertainment,” Imperial College London COVID-19 Reports, no. 31, Sep. 15, 2019, https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-31-syria/.

[11] Interview with JO03 on September 1, 2020.

[12] Ibid.

[13] World Health Organization, “HeRAMS Annual Report,” 2020, https://apps.who.int/iris/bitstream/handle/10665/333184/WHOEMSYR039E-eng.pdf?sequence=1&isAllowed=y.

[14] World Health Organization, “HeRAMS Annual Report.”

[15] Human Rights Watch, “Syria: Detention, Harassment in Retaken Areas,” May 21, 2019, https://www.hrw.org/news/2019/05/21/syria-detention-harassment-retaken-areas#:~:text=(Beirut)%20%E2%80%93%20Syrian%20intelligence%20branches,Human%20Rights%20Watch%20said%20today.&text=The%20government%20retook%20these%20areas,between%20February%20and%20August%202018; Abdullah al-Jabassini, “The Baath Party, Local Notables and Coronavirus Community Response Initiatives in Southern Syria,” Wartime and Post-Conflict in Syria (WPCS), May 4, 2020,
https://cadmus.eui.eu/bitstream/handle/1814/66968/RPR_2020_08.pdf?sequence=1&isAllowed=y; International Crisis Group, Lessons from the Syrian State’s Return to the South, no. 196, Feb. 28, 2019, https://d2071andvip0wj.cloudfront.net/196-lessons-from-syria_0.pdf.  

[16] Interview JO08 on October 14, 2020 and Abdullah al-Jabassini, “Festering Grievances and the Return to Arms in Southern Syria,” Wartime and Post-Conflict in Syria (WPCS), April 7, 2020, https://cadmus.eui.eu/bitstream/handle/1814/66786/Festering%20Grievances%20and%20the%20Return%20to%20Arms%20in%20Southern%20Syria-final.pdf?sequence=1&isAllowed=y.

[17] World Health Organization, “HeRAMS Annual Report.”

[18] France24, “Syria devalues currency as new US sanctions hit,” France24, June 17, 2020, https://www.france24.com/en/20200617-syria-devalues-currency-as-new-us-sanctions-hit.

[19] Interview with JO03 on September 1, 2020.

[20]Nearly 595 attacks on health care through February 2020 have occurred, and 923 health care professionals have been killed since the beginning of the conflict. The overwhelming majority of these attacks are attributed to the Syrian government and its allies, mostly occurring in opposition-controlled areas or conflict zones. Physicians for Human Rights, “Medical Personnel Are Targeted in Syria,” https://phr.org/our-work/resources/medical-personnel-are-targeted-in-syria/#:~:text=PHR%20has%20assessed%20that%20the,medical%20personnel%20throughout%20the%20conflict.&text=The%20targeting%20of%20medical%20personnel,responsible%20must%20be%20held%20accountable.

[21] Humanitarian Needs Overview, “2019 Humanitarian Needs Overview,” https://hno-syria.org/#home, and United Nations High Commissioner for Refugees, “Situation Syria Regional Refugee Response,” accessed November 11, 2020, https://data2.unhcr.org/en/situations/syria.

[22] Anne Barnard, “Death Toll From War in Syria now 470,000, Group Finds,” The New York Times, Feb. 11, 2016, https://www.nytimes.com/2016/02/12/world/middleeast/death-toll-from-war-in-syria-now-470000-group-finds.html?_r=1; Ian Black, “Report on Syria Conflict finds 11.5% of population killed or injured,” The Guardian, Feb. 11, 2016, https://www.theguardian.com/world/2016/feb/11/report-on-syria-conflict-finds-115-of-population-killed-or-injured

[23] The World Bank, The Toll of War: The Economic and Social Consequences of the Conflict in Syria, July 10, 2017, https://www.worldbank.org/en/country/syria/publication/the-toll-of-war-the-economic-and-social-consequences-of-the-conflict-in-syria.

[24] World Health Organization, “HeRAMS Annual Report (January – December 2019): Public Hospitals in the Syria Arab Republic,” 2020, https://apps.who.int/iris/bitstream/handle/10665/333184/WHOEMSYR039E-eng.pdf?sequence=1&isAllowed=y.

[25] Population numbers as of 2004. “Syrian Arab Republic Office of Prime Minister: Central Bureau of Statistics,” http://cbssyr.sy/index-EN.htm.

[26] Daraa governorate is slightly larger than the state of Rhode Island in the United States (1,212 square miles).

[27] Haian Dukhan, “Tribes and Tribalism in the Syrian Uprising,” Syria Studies 6, no. 2, (2014), https://ojs.st-andrews.ac.uk/index.php/syria/article/view/897/746.

[28] Ibid.

[29] Agence France-Presse, “Graffiti boys who sparked Syria uprising brace for regime attack,” N World, June 16, 2018, https://www.thenationalnews.com/world/mena/graffiti-boys-who-sparked-syria-uprising-brace-for-regime-attack-1.740678.

[30] Hugh Macleod and Annasofie Flamand, “Tortured and killed: Hamza al-Khateeb, age 13,” Al Jazeera, May 31, 2011, https://www.aljazeera.com/features/2011/5/31/tortured-and-killed-hamza-al-khateeb-age-13.

[31] Suleiman al-Khalidi, “Numbers of displaced in southern Syria climbs to 270,000: U.N.,” Reuters, July 2, 2018, https://www.reuters.com/article/us-mideast-crisis-syria-un-displaced-idUSKBN1JS11T; Fouad M. Fouad et al., “Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet-American University of Beirut Commission on Syria,” The Lancet 390, 10111, (December 2018), https://www.sciencedirect.com/science/article/abs/pii/S0140673617307419.

[32] Population estimates as of 2014. Syrian Arab Republic: Central Bureau of Statistics, “Mashrou’ Taqreer Halat al Sukan 2014 [Project for the Status of the Population 2014],”  http://cbssyr.sy/population_statuse/%D9%85%D8%AD%D8%A7%D9%81%D8%B8%D8%A9_%D8%AF%D8%B1%D8%B9%D8%A7.pdf. The Central Bureau of Statistics has not published updated population figures for Daraa since 2014.

[33] Interview with JO07 on September 15, 2020, see also Fouad et al., “Weaponisation of health care,” 2516-2526. (Noting that a significant part of the government’s strategy to reclaim opposition areas was the destruction of civilian health services).

[34]Armenak Tokmajyan, “How Southern Syria Has Been Transformed Into a Regional Powder Keg,” Carnegie Middle East Center, July 14, 2020, https://carnegie-mec.org/2020/07/14/how-southern-syria-has-been-transformed-into-regional-powder-keg-pub-82202.

[35] World Health Organization, “Syrian Arab Republic: WHO Coronavirus Disease (COVID-19) Dashboard,” accessed November 16, 2020, https://covid19.who.int/region/emro/country/sy

[36] Oliver J. Watson, et al., “Estimating the burden of COVID-19 in Damascus, Syria: an analysis of novel data sources to infer mortality under-ascertainment,” Imperial College London COVID-19 Reports, no. 31, Sep. 15, 2019, https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-31-syria/.

[37] The sanctions resulted in an immediate devaluation of the Syrian pound; the central bank raised the official exchange rate with the dollar from 704 to 1,256 within weeks of the Caesar Act coming into effect. France24, “Syria devalues currency as new US sanctions hit,” France24, June 17, 2020 https://www.france24.com/en/20200617-syria-devalues-currency-as-new-us-sanctions-hit, see also Sam Heller, “What are America’s Sanctions on Syria Good for?,” War on the Rocks, Sep. 29, 2020, https://warontherocks.com/2020/09/what-are-americas-sanctions-on-syria-good-for/.

[38] The World Health Organization (WHO) uses the term “human resources for health” to describe health care workers in different domains of health systems including in the private and public sectors. WHO, Human resources for health (HRH) tools and guidelines, available at World Health Organization, “Health workforce: Human resources for health (HRH) tools and guidelines,” accessed November 17, 2020,  https://www.who.int/hrh/tools/planning/en/.

[39] Sara Kayyali, Rigging the System: Government Policies Co-Opt Aid and Reconstruction Funding in Syria, June 28, 2019, https://www.hrw.org/report/2019/06/28/rigging-system/government-policies-co-opt-aid-and-reconstruction-funding-syria; Jesse Marks, “Humanitarian aid in Syria is being politicized – and too many civilians in need aren’t getting it,” Washington Post, August 6, 2019, https://www.washingtonpost.com/politics/2019/08/06/humanitarian-aid-syria-is-being-politicized-too-many-civilians-need-arent-getting-it/; Jacob Kurtzer, “Never more Necessary: Overcoming humanitarian access challenges,” Center for Strategic and International Studies,2019,https://www.csis.org/features/never-more-necessary-overcoming-humanitarian-access-challenges.

[40] The team assigned codes to each respondent based on their country of residence and participant number. (i.e., JO01 for the first participant in Jordan).

[41] The right to health is contained both in article 22(2) of the Syrian Arab Republic Constitution (2012) and in Article 12 of the ICESR. Section 4 of this report contains a discussion of legal and policy implications.

[42] Cross-border humanitarian activity from Jordan began prior to the passing of UNSCR2165 in mid-2014. Marcello, Tamara. Cross-border operations from Jordan to Syria under UN Security Council Resolution 2165 2014-2018. June 2019.

[43] Sumaira Akbarzada and Tim K. Mackey, “The Syrian public health and humanitarian crisis: A ‘displacement’ in global governance?,” Global Public Health, 13:7, (February 4, 2017): 914-930,  https://www.tandfonline.com/doi/abs/10.1080/17441692.2017.1285338?journalCode=rgph20.

[44] The capital of Daraa governorate, Daraa City, was divided between the opposition and the government 2012-18. The capital of Daraa governorate, Daraa City, was divided between the opposition and the government 2012-18. UN Habitat, City Profile Dara’a: Multi Sector Assessment, Jun. 2014, https://unhabitat.org/sites/default/files/download-manager-files/Daraa%20CP.pdf.

[45] There are two primary ways of delivering humanitarian aid into affected areas: either from other countries, such as Jordan or Turkey, via “cross-border” convoys, or from within Syria, delivering supplies from government-held to opposition-held areas, referred to as “cross-line” convoys. For an overview, see Emma Beals and Nick Hopkins, Guardian briefing: the key questions around aid in Syria,” The Guardian, October 28, 2016, https://www.theguardian.com/world/2016/oct/28/syria-aid-relief-effort-key-questions-guardian-briefing.

[46] Interview with JO01 on August 25, 2020.

[47] Within the United Nations, the Cluster Approach is a way of organizing coordination and cooperation among humanitarian actors to facilitate joint strategic planning. WHO, Health Cluster Guide: A practical guide for country-level implementation of the Health Cluster, June 2009, available at World Health Organization, “Health Cluster Guide: A practical guide for country-level implementation of the Health Cluster,” June 2009, https://www.who.int/hac/network/global_health_cluster/health_cluster_guide_6apr2010_en_web.pdf.

[48] Interview with JO01 on August 25, 2020.

[49] Interview with US01 on August 26, 2020.

[50] Abdullah al-Jabassini, “From Rebel Rule to a Post-Capitulation Era in Daraa Southern Syria: The Impacts and Outcomes of Rebel Behaviour During Negotiations,” RSCAS 2019/06, January 2019, https://cadmus.eui.eu/bitstream/handle/1814/60664/RSCAS_2019_06.pdf.

[51] Physicians for Human Rights, “Physicians for Human Rights’ Findings of Attacks on Health Care in Syria,” accessed October 13, 2020, http://syriamap.phr.org/#/en/findings.

[52] Three hundred and ten beds versus the original inpatient capacity of 810 beds. World Health Organization, “HeRAMS Annual Report.” Note that only 50 percent of public hospitals across Syria were fully functional at the end of 2019, with an additional 25 percent reported partially functioning due to damage to the building or shortages of staff or supplies.

[53] For a visual database of attacks on facilities and personnel in Syria beginning in 2011, see Physicians for Human Rights, “Map of Attacks.”

[54] For the use of the term reconciliation in this report, see note 1 above. For a brief historical overview of reconciliation agreements before 2018 see Raymond Hinnebush, and Omar Imady, Syria’s Reconciliation Agreements,” The Day After: Post-uprising Realities and Challenges, 9:2, (2017), https://ojs.st-andrews.ac.uk/index.php/syria/article/view/1558. See also International Crisis Group, “Keeping the Calm in Southern Syria,” Middle East Report, no. 187, Jun. 21, 2018, https://www.crisisgroup.org/middle-east-north-africa/eastern-mediterranean/syria/187-keeping-calm-southern-syria

[55] Syrian Arab Republic, “Legislative Decree 15 and 23,” October 27, 2016, http://www.parliament.gov.sy/arabic/eindex.php?node=554&cat=17002&nid=17002&print=1&pm=1.

[56] Ministry of Foreign Affairs Russia, “Memorandum on the creation of de-escalation areas in the Syrian Arab Republic,” May 6, 2017, https://www.mid.ru/en/foreign_policy/news/-/asset_publisher/cKNonkJE02Bw/content/id/2746041.

[57] Other areas for de-escalation included Idlib governorate and certain parts of Aleppo, Hama, and Latakia governorates; northern Homs; and eastern Ghouta.

[58] Although that agreement remains unpublished, for details see “Press briefing on the President’s Meetings at the G20,” The White House, 7 July 2017, www.whitehouse.gov/briefings-statements/press-briefing-presidents-meetings-g20-070717/; “Background Briefing on the Ceasefire in Syria”, U.S. Department of State, 7 July 2017, www.state.gov/r/pa/prs/ps/2017/07/272433.htm.

[59] International Crisis Group, “Appendices,” Lessons from the Syrian State’s Return to the South, no. 196, Feb. 28, 2019, https://d2071andvip0wj.cloudfront.net/196-lessons-from-syria_0.pdf. These appear to be the only published agreements.

[60] Ibid., see also al-Modon, “Daraa ‘Iteefaqat Munfarida Bibunud Ghamida [Daraa: Individual Agreements with Unclear Clauses],” July 17, 2018, https://www.almodon.com/print/607ac4ab-1f1e-41e5-95e1-487ce7b405af/e3b61837-0690-4c37-924d-0ad690952b46.

[61] Interview with JO01 on August 25, 2020.

[62] WASL Campaign, “Facts on Syria,” https://wasl-network.eu/campaign/.

[63] Note that even though private providers increased by 41 percent since economic reforms beginning in 2005, 80 percent of Syria’s hospital beds were in the public sector prior to the war. Kasturi Sen, and Waleed al-Faisal, “Syria: Neoliberal Reforms in Health Sector Financing: Embedding Unequal Access?,” Social Medicine 6, no. 3, March 2012 https://www.socialmedicine.info/index.php/socialmedicine/article/view/572/1207. (“Current estimates suggest that more than two thirds of the population continue to use public inpatient facilities.”). According to Syrian health system experts, an estimated 60 percent of doctors (excluding dentists) had some form of employment with the public sector. Dr. Samer Jabbour, Personal Communication, November 17, 2020. 

[64] Interviews with JO07 on September 15, 2020 and JO08 on October 14, 2020.

[65] Interview with JO08 on October 14, 2020.

[66] Abdullah al-Jabassini, “Festering Grievances and the Return to Arms in Southern Syria,” Wartime and Post-Conflict in Syria (WPCS), April 7, 2020 https://cadmus.eui.eu/bitstream/handle/1814/66786/Festering%20Grievances%20and%20the%20Return%20to%20Arms%20in%20Southern%20Syria-final.pdf?sequence=1&isAllowed=y.

[67] For example, destroyed hospitals and clinics remain unused, and medical equipment looted from humanitarian-run clinics has not been replaced in public facilities. Interviews with TU04 on September 17, 2020 and JO08 on October 14, 2020.

[68] Interview with JO07 on September 15, 2020.

[69] United Nations Office for the Coordination of Humanitarian Affairs, “Syrian Arab Republic: United Nations cross-border operations from Jordan to Syria,” December 12, 2018, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/cnv_syr_xb_jordan_en_june2018_180705v4.pdf. Note that while some actors were allowed to run health facilities for a temporary period, by the end of 2018, almost all of the humanitarians active in the health sector since 2012 had to close.

[70] Syrian Association for Citizen’s Dignity, ““Reconciliation agreement” in Daraa: Insecurity, continued repression and collective punishment,” July 10, 2020, https://syacd.org/reconciliation-agreement-in-daraa-insecurity-continued-repression-and-collective-punishment/.

[71] Interview with JO05 on September 8, 2020.

[72] Interview with JO05 on September 8, 2020.

[73] Interview with JO04 on September 3, 2020.

[74] Interview with TU02 on August 26, 2020.

[75] Human Rights Watch, “Syria: Detention, Harassment in Retaken Areas,” May 21, 2019, https://www.hrw.org/news/2019/05/21/syria-detention-harassment-retaken-areas#:~:text=(Beirut)%20%E2%80%93%20Syrian%20intelligence%20branches,Human%20Rights%20Watch%20said%20today.&text=The%20government%20retook%20these%20areas,between%20February%20and%20August%202018; Abdullah al-Jabassini, “The Baath Party, Local Notables and Coronavirus Community Response Initiatives in Southern Syria,” Wartime and Post-Conflict in Syria (WPCS), May 4, 2020,
https://cadmus.eui.eu/bitstream/handle/1814/66968/RPR_2020_08.pdf?sequence=1&isAllowed=y; International Crisis Group, Lessons from the Syrian State’s Return to the South, no. 196, Feb. 28, 2019, https://d2071andvip0wj.cloudfront.net/196-lessons-from-syria_0.pdf.  

[76] Interviews with JO05 on September 8, 2020 and JO04 on September 3, 2020.

[77] Interview JO08 on October 14, 2020.

[78] “Report of the Independent International Commission of Inquiry on the Syrian Arab Republic,” United Nations Human Rights Council, August 14, 2020, A/HRC/45/31, https://undocs.org/A/HRC/45/31.

[79] Interview with JO07 on September 15, 2020.

[80] Interview with JO08 on October 14, 2020.

[81] World Health Organization, “HeRAMS Annual Report.”

[82] Population figures in Syria are a politically sensitive and complicated issue. The lack of clear official population data illustrates the significant data gap this report identifies. The HeRAMS report (2020) which is the source of this data provides this breakdown but no population figures, citing the Central Bureau of Statistics for the unpublished data. Note the most recent published official Central Bureau of Statistics report dates to 2014, estimating the population of Daraa was 680,404. In 2018, the UNOCHA estimated displacement of 270,00 during the 2018 fighting. There is no accurate, publicly available current population number for Daraa. Note that the Inter-Agency Standing Committee (IASC) standards for health staff per 10,000 people is 22. Daraa has only 5.7 HCWs per 10,000, compared to 41.7 per 10,000 in Damascus.

[83] Interview with SY01 on September 21, 2020.

[84] The lack of clinical training for psychologists is in part due to the educational system in Syria. Students of psychology in Syria receive theoretical instruction but no clinical training. Given the need for humanitarian psychosocial positions, some students of psychology and educational psychology have become case workers, providing one -on -one and group counseling as well as psychosocial activities, but these professionals do not have any formal clinical training.

[85] Interview with JO02 on September 16, 2020.

[86] Interview with SY01 on September 21, 2020.

[87] The HeRAMS report defines a hospital that is “fully functioning” as open, accessible, and provides healthcare services with full capacity (i.e., staffing, equipment, and infrastructure). WHO Regional Office for the Eastern Mediterranean. World Health Organization, “HeRAMS Annual Report.” For details about specific attacks by the Syrian government on hospitals in Daraa, see Physicians for Human Rights, Illegal Attacks on Health Care in Syria Map, http://syriamap.phr.org/#/en (accessed 20 November 2020).

[88] Interview with JO08 on October 14, 2020.

[89] Note that information about functioning private facilities in Daraa is not available.

[90] Data collected via a survey conducted in Daraa by the Syrian Center of Media and Freedom of Expression via its Violation Documentation Center in Syria in Spring 2020. See also Physicians for Human Rights “Map of Attacks,” (“Government forces occupied Jasim National Hospital and turned it into headquarters. In December 2013, opposition forces targeted the inoperative hospital and captured it on January 7, 2014.”).

[91] Data collected via a survey conducted in Daraa by the Syrian Center of Media and Freedom of Expression via its Violation Documentation Center in Syria in Spring 2020.

[92] Interview with JO08 on October 14, 2020.

[93] Interview with UK02 on September 11, 2020.

[94] Sarah Dadouch, “Coronavirus is out of control in Syria, no matter what the government says,” The Washington Post, Sept. 25, 2020, https://www.washingtonpost.com/world/middle_east/syria-coronavirus-outbreak-doctors/2020/09/24/95d9323a-fcea-11ea-b0e4-350e4e60cc91_story.html.

[95] Interviews with UK02, JO01, JO02, JO03, JO06, JO07, US01, TU02, TU04, and SY02. Note that multiple respondents indicated that, while serious, the focus on COVID -19 should not divert attention from the larger systemic problem of health service discrimination against Daraa post -reconciliation.

[96] Interview with JO02 on September 16, 2020.

[97] Interview with TU04 on September 17, 2020.

[98] Interview with SY02 on September 25, 2020 and JO07 on September 15, 2020.

[99] Interview with TU04 on September 17, 2020 and VDC, Respondent 3 and Respondent 4 (data collected via a survey conducted in Daraa by the Syrian Center of Media and Freedom of Expression via its Violation Documentation Center in Syria in Spring 2020)

[100] Interview with TU03 in September 9, 2020 and JO03 September 1, 2020.

[101] Interviews with JO03, JO04, SY01, and JO05.

[102] There is controversy among researchers regarding the number of ventilators available. A March 2020 London School of Economics (LSE) study estimated there were only three ICU beds with ventilators in Daraa, with capacity to support a maximum of 60 COVID-19 cases. In contrast, the same study estimated 96 ICU beds with ventilators are available in Damascus, followed by 77 in Latakia, 30 in Tartus, and 29 in Hama. The LSE authors’ calculations were based on data from the WHO, Central Bureau of Statistics, and Idlib Health Directorate. See Mazen Gharibah and Zaki Mehchy, Covid-19 Pandemic: Syria’s Response and Healthcare Capacity, Mar. 25, 2020, http://eprints.lse.ac.uk/103841/1/CRP_covid_19_in_Syria_policy_memo_published.pdf. But see al-Jabassini, “Response Initiatives in Southern Syria.” (“According to several interviews with medical staff at Daraa’s functioning public and private hospitals, there are a total of 31 intensive care unit (ICU) beds with ventilators in Daraa as of April 2020.”).

[103] Population estimate as of 2014. Central Bureau of Statistics “Mashrou’ Taqreer Halat al-Sukan 2014.” 

[104] Interview with TU04 on September 17, 2020 and NT01 on September 30, 2020.

[105] E.g. Busra al-Sham Hospital and the main hospital in Tafas. See Reem Salahi, “Syrians Respond to COVID-19 with Renewed Volunteer and Community Efforts,” MEI, June 17, 2020,
https://www.mei.edu/publications/syrians-respond-covid-19-renewed-volunteer-and-community-efforts, and al-Jabassini, “Response Initiatives in Southern Syria.”

[106] Interview with JO07 on September 15, 2020.

[107] Interview with TU04 on September 17, 2020.

[108] Interview with JO07 September 15, 2020.

[109] Qussai Jukhadar and Elizabeth Tsurkov, “How the Syrian Regime Undermines the Response to COVID-19,”
October 13, 2020, https://cgpolicy.org/articles/how-the-syrian-regime-undermines-the-response-to-covid-19/?s=08.

[110] Interview with US02 on October 16, 2020.

[111] Interview with TU01 on September 10, 2020.

[112] Interviews with NT01, US01, UK02, and JO01.

[113] Interview with US01 on August 26, 2020.

[114] Interview with JO06 on August 25, 2020.

[115] Note that after the first few months of the pandemic, the researcher confirmed that the government had reduced the use of intelligence services to monitor reports of COVID-19 in the country. Interview with TU04 on September 17, 2020.

[116] Interview with TU04 on September 17,2020.

[117] Interview with JO04 on September 3, 2020. See also, Okba Mohammed, “In Assad-controlled Syria, the official narrative is ‘no COVID-19 cases’,” trans. Mariam Abuadas, Global Voices, July 16, 2020,https://globalvoices.org/2020/07/16/in-assad-controlled-syria-the-official-narrative-is-no-covid-19-cases/.

[118] Interviews with JO02 on September 16, 2020 and with SY01 on September 21, 2020.

[119] Interviews with SY01 on September 21, 2020 and UK02 on September 11, 2020.

[120] Humanitarian Needs Assessment Programme, “Syrian Arab Republic: Regional COVID-19 Vulnerability Map,” November 10, 2020.

[121] Humanitarian Needs Assessment Programme, “COVID-19 Rapid Assessment: Government of Syria Controlled Area.” November 17, 2020.

[122] UN Office for the Coordination of Humanitarian Affairs (OCHA), “Syrian Arab Republic: COVID-19; Humanitarian Update No. 17,” September 1, 2020, https://reliefweb.int/sites/reliefweb.int/files/resources/Syria_COVID-19_Humanitarian%20Update_No%2017_1Sept2020_FINAL.pdf

[123] Interviews with TU04 on September 17, 2020

[124] Interview with JO03 on September 1, 2020.

[125] Humanitarian Needs Assessment Programme, “COVID-19 Rapid Assessment.”

[126] Interview with SY02 on September 25, 2020.

[127] Interview with JO04 on September 3, 2020.

[128] Interview with JO03 on September 1, 2020.

[129] Interviews with UK02 on September 11, 2020 and TU02 on August 26, 2020. See also Danny Makki, “Syria is facing a COVID-19 catastrophe,” MEI, August 6, 2020 https://www.mei.edu/publications/syria-facing-covid-19-catastrophe and Virgina Pietromarchi, “In COVID-hit Syria, people ‘prefer to die than come to hospital’,” Al Jazeera,October 5, 2020,https://www.aljazeera.com/features/2020/10/5/covid-19-syria-hospital.

[130] Interview with UK02 on September 11, 2020.

[131] Interview with TU01 on September 10, 2020.

[132] In a high-profile case, the dean of medicine of the University of Damascus was fired after he publicly disagreed with the government’s policy to reopen schools. See Dadouch, “Coronavirus in Syria.”

[133] Independent media reports have raised the concern that in the first months of the pandemic, the government may have endorsed violence to silence patients and their providers. See, e.g., Mohammed, “In Assad-controlled Syria;” March 15, 2020 (opposition website) Sawt al-Aasima, “Dimashq: ‘In Asubta bi Corona… Sataqtuluka Mashafi Alnizam [Damascus: If you are infected with Corona… hospital governments will kill you]” https://damascusv.com/archives/21676.

[134] Interview with JO03 on September 1, 2020.

[135] The case allegedly occurred in Damascus Countryside governorate. Interview with TU04 on September 17, 2020.

[136] Interview with SY02 on September 25, 2020.

[137] While the Jordanian government has regulated the closure, and recent reopening on September 27, 2020 of the border and measures to protect Jordanian custom officials from Syrian truck drivers, the Syrian government has not expressed any intent to regulate or monitor interactions at border crossings.Suleiman al-Khalidi, “Jordan Reopens Trade Gateway with Syria after Month-Long COVID Closure,” Reuters, September 27, 2020, https://www.reuters.com/article/us-health-coronavirus-jordan-syria/jordan-reopens-trade-gateway-with-syria-after-month-long-covid-closure-idUSKBN26I0W5.

[138] Interview with SY01 on September 21, 2020.

[139] Interview with JO02 on September 16, 2020.

[140] Interviews with UK02 on September 11, 2020 and JO05 on September 8,2020.

[141] Interviews with UK02 on September 11, 2020, NT01 on September 30, 2020, and JO07 on September 15, 2020.

[142] Human Rights Watch, “Syria: Health Workers Lack Protection in Pandemic,” September 2, 2020, https://www.hrw.org/news/2020/09/02/syria-health-workers-lack-protection-pandemic.

[143] Interview with JO04 on September 3, 2020.

[144]The New Arab, “COVID-19 Deaths Spike among Syria Medical Personnel,” Aug. 17, 2020, https://english.alaraby.co.uk/english/news/2020/8/17/covid-19-deaths-spike-among-syria-medical-personnel.

[145] Interview with UK02 on September 11, 2020.

[146] See Annex 1, World Food Programme, The Socio-Economic Impacts of the COVID-19 Pandemic in the Syrian Arab Republic (April – June 2020), October 2020, available at United Nations World Food Programme (WFP), “The Socio-economic impacts of the Covid-19 Pandemic in the Syrian Arab Republic April – June 2020,” October 2020, https://reliefweb.int/sites/reliefweb.int/files/resources/WFP-0000120093-compressed.pdf.

[147] Interviews with JO01 on August 25, 2020 and SY01 on September 21, 2020. Note that in an indication of the lack of health system data in Daraa, a full list of NGOs that operate there is not publicly available.

[148] This is funding put forth by the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) as a part of the Syria Humanitarian Response Plan: UN Office for the Coordination of Humanitarian Affairs Financial Tracking Service, “Syrian Arab Republic 2019,” 2019, https://fts.unocha.org/countries/218/flows/2019?f%5B2%5D=destinationPlanIdName%3A924%3ASyria+Humanitarian+Response+Plan+2020.

[149] Interview with SY01 on September 21, 2020.

[150] Interview with SY01 on September 21, 2020 and JO02 on September 16, 2020.

[151] Interview with JO04 on September 3, 2020.

[152] For an overview of the regime’s violations of international humanitarian aid provision, see Vincent Bernard, “Conflict in Syria: Finding Hope amid the Ruins,” International Review of the Red Cross 99, no. 906 (2017), https://www-cambridge-org.ezproxy.cul.columbia.edu/core/journals/international-review-of-the-red-cross/article/conflict-in-syria-finding-hope-amid-the-ruins/1BB19C61B2BEA7F721D68BD39FBFC3F9; ICRC Customary IHL Database, “Practice Relating to Rule 55. Access for Humanitarian Relief to Civilians in Need,”https://ihl-databases.icrc.org/customary-ihl/eng/docs/v2_rul_rule55. In response, U.N. Security Council resolution 2165 (2014) authorized cross-border and cross-line access for the UN and its partners to deliver humanitarian aid in Syria without state consent. Opposition-held northern areas are dependent on cross-border and cross-line aid, which continue to be hotly contested. Resolution 2533 (2020) renewed the Bab al-Hawa border crossing (Syria/Turkey) until 10 July 2021. Three Security Council members (China, the Dominican Republic and Russia) abstained. 

For a full list of relevant Security Council resolutions, see UN Documents for Syria: Security Council Resolutions, available at Security Council Report, “UN Documents for Syria: Security Council Resolutions,” https://www.securitycouncilreport.org/un_documents_type/security-council-resolutions/page/1?ctype=Syria&cbtype=syria#038;cbtype=syria.

[153] Interview with TU01 on September 10, 2020, JO04 on September 3, 2020 and SY01 on September 21, 2020.

[154] Interview with JO01 on August 25, 2020, and JO02 on September 16, 2020.

[155] Interview with JO04 on September 3, 2020.

[156] Interview with JO02 on September 16, 2020.

[157] Interview with JO02 on September 16, 2020.

[158] SARC activities include distribution of medications through a handful of static primary health clinics and mobile medical units. Interviews with SY01, TU04, TY02, and NT01.

[159] Interviews with NT01 on September 30, 2020 and UK02 on September 11, 2020.

[160] Interview with TU01 on September 10, 2020.

[161] Interview with JO01 on August 25, 2020.

[162] Interview with TU04 on September 17, 2020 and JO05 on September 8, 2020.

[163] Interview with TU04 on September 17, 2020. Regime -affiliated local charities reportedly also operate without adherence to humanitarian standards of neutrality. See also Human Rights Watch, “Syria: Aid Restrictions Hinder Covid-19 Response,” April 28, 2020, https://www.hrw.org/news/2020/04/28/syria-aid-restrictions-hinder-covid-19-response.

[164] Interview with JO07 on September 15, 2020.

[165] Interview with NT01 on September 30, 3030.

[166] Interview with TU02 on August 26, 2020. For a published article in which the Syrian President makes this statement, see al-Akhbar, “Al-Assad on easing the partial ban: There is no prevention of hunger except by action,” May 4, 2020, https://al-akhbar.com/Syria/288122.

[167] The role of sanctions lies outside the scope of this paper. However, many civilians attribute deteriorating economic conditions to the recently imposed sanctions from Western governments, including the U.S. Caesar Act and additional sanctions from the European Union. Qussai Jukhadar and Elizabeth Tsurkov, “Caesar Act: The Syrian People Are Sapped While Assad Grows Stronger,” September 18, 2020, https://www.atlanticcouncil.org/blogs/menasource/caesar-act-the-syrian-people-are-sapped-while-assad-grows-stronger/.

[168] Interview with UK01 on September 4, 2020 and SY01 on September 21, 2020. When the border with Lebanon closed because of COVID-19, medication shortages in Syria escalated. With this internal supply chain disrupted, people everywhere, including in Daraa, have struggled to find necessary medications at the pharmacy. Essential medications for hypertension and diabetes are mostly unavailable. 

[169] Samer Hamati, “Computing Pre-conflict Poverty Data in Syria,” IDEAS, September 2019, 3-18, https://ideas.repec.org/p/ipc/wpaper/185.html.

[170] Enab Baladi, “Severe Gas Crisis in Daraa: Syrians Resort to Firewood and Electricity,” June 2, 2020, https://english.enabbaladi.net/archives/2019/12/severe-gas-crisis-in-daraa-syrians-resort-to-firewood-and-electricity/.

[171] Interview with US01 on August 26, 2020.

[172] Interview with SY02 on September 25, 2020.

[173] Interview with SY02 on September 25, 2020.

[174] Interview with US01, UK01, TU04, and VDC, Respondent 4 (data collected via a survey conducted in Daraa by the Syrian Center of Media and Freedom of Expression via its Violation Documentation Center in Syria in Spring 2020).

[175] Interviews with UK01 on September 11, 2020 and TU04 on September 17,2020. Oxygen tanks on the black market were estimated by interviewees to cost 150,000-300,000 SYP (($293-585 USD).

[176] Interviews with JO01, JO03, TU02, SY01, and US01.

[177] Interview with US01 on August 26, 2020.

[178] Walid al-Nofal, “Assassinations Escalate in Daraa as 2nd Anniversary of ‘Reconciliation’ Nears,” July 27, 2020, https://syriadirect.org/news/assassinations-escalate-in-daraa-as-2nd-anniversary-of-%E2%80%9Creconciliation%E2%80%9D-nears/.

[179] Walid al-Nofal, “Will the Security Crisis in Southern Syria Spark a ‘New Revolution’?,” January 2020, https://syria.chathamhouse.org/research/will-the-security-crisis-in-southern-syria-spark-a-new-revolution. Since reconciliation, estimates indicate that more than 425 people have been killed in Daraa, including current and former aid workers, combatants, non-combatants, and political officials. See, e.g., Chloe Cornish, “Assassinations in Southern Syria Expose Limits of Assad’s Control,” April 28, 2020, https://www.ft.com/content/ea48ebb9-cde0-4856-b6a4-49d00c70067c.

[180] Interview with SY01 on September 21, 2020.

[181] Asharq al-Awsat, “Two Oxfam Workers Killed in Syria’s Daraa,” February 20, 2020, https://english.aawsat.com//home/article/2140506/two-oxfam-workers-killed-syrias-daraa.

[182] Tokmajyan, “Southern Syria Transformed.”

[183] Interview with JO03 on September 1, 2020.

[184] Interview with NT01 on September 30, 2020.

[185] Interview with JO07 on September 15, 2020.

[186] Interview with JO03 on September 1, 2020.

[187] Interview with TU04 on September 17, 2020.

[188] For a discussion of the relevant international humanitarian law, see Physicians for Human Rights, “Overview of Principles and Rules of International Humanitarian Law Applicable to Conduct of Hostilities with a Focus on Targeting of Hospitals and Medical Unites,” https://s3.amazonaws.com/PHR_syria_map/ihl-methodology-appendix.pdf. For a discussion of the attacks on medical personnel in Syria, see Rayan Koteiche, Serene Murad, and Michele Heisler, My Only Crime Was That I Was a Doctor, December 4 2019, https://phr.org/wp-content/uploads/2019/12/PHR-Detention-of-Syrian-Health-Workers-Full-Report-Dec-2019_English-1.pdf 

[189] Syrian Arab Republic, “Constitution of the Syrian Arab Republic,” 2012,  https://www.ilo.org/dyn/natlex/docs/ELECTRONIC/91436/106031/F-931434246/constitution2.pdf.

[190] International Covenant on Economic, Social and Cultural Rights, Syria acceded April 21, 1969. United Nations Treaty Collection “Human Rights: International Covenant on Economic, Social, and Cultural Rights,” https://treaties.un.org/pages/ViewDetails.aspx?src=IND&mtdsg_no=IV-3&chapter=4&clang=_en.

[191] Human Rights Watch, “Health Workers Lack Protection.”

[192] Matthew Parsons, Kathleen Fallon, and Natasha Kieval, Madaya: Portrait for a Syrian Town Under Siege, July 1, 2016, https://phr.org/our-work/resources/madaya-portrait-of-a-syrian-town-under-siege/.

[193] Interview with TU04 on September 17, 2020.

[194] Emphasis added. United Nations Security Council, “Resolution 2254 (2015),” December 18, 2015, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_res_2254.pdf.

[195] International Covenant on Civil and Political Rights (ICCPR), Article 19 (“seek, receive and impart”), available at United Nations Office of the High Commissioner, “International Covenant on Civil and Political Rights,” December 16, 1966,  https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx; see also, Universal Declaration of Human Rights (UDHR), Article 19 (“seek, receive and impart”), available at United Nations, “Universal Declaration of Human Rights,” December 10, 1948 https://www.un.org/en/universal-declaration-human-rights/; African Charter on Human and Peoples’ Rights (ACHPR), Article 9 (“the right to receive information . . . the right to express and disseminate his opinions”), available at: African Commission on Human and Peoples’ Rights, “African Charter on Human and Peoples’ Rights,” July 1979,  https://www.achpr.org/legalinstruments/detail?id=49; European Convention on Human Rights (ECHR), Article 10 (“to receive and impart), available at: European Court of Human Rights. “European Convention on Human Rights,” 1950, https://www.echr.coe.int/Documents/Convention_ENG.pdf; and American Convention on Human Rights (ACHR), Article 13 (“seek, receive and impart”), available at: Organization of American States, “American Convention on Human Rights,” http://www.oas.org/dil/treaties_B-32_American_Convention_on_Human_Rights.htm. Note that restrictions on this right are permissible only by law and “for the protection of national security or of public order (ordre public), or of public health or morals.” Article 19(3)(b). See also, UN Human Rights Committee, General Comment No. 34, Article 19: Freedoms of opinion and expression, 12 September 2011, CCPR/G/GC/34, para. 18. Available at: United Nations Human Rights Committee, “General Comment No. 34,” September 12, 2011, http://undocs.org/ccpr/c/gc/34.

[196] The right to life is articulated in Article 3 of the United Nations, “Universal Declaration of Human Rights.”

[197] Centre for Law and Democracy, “Maintaining Human Rights during Health Emergencies: Brief on Standards Regarding the Right to Information,” May 2020, https://www.argentina.gob.ar/sites/default/files/rti-and-covid-19-briefing.20-05-27.final_.pdf. (“The UN Human Rights Committee, the Inter-American Commission on Human Rights and the special international mandates on freedom of expression at the UN, OSCE and OAS, have reaffirmed that freedom of expression and the right to information are critical at this time.”)

[198] United Nations Committee on Economic, Social and Cultural Rights, “General Comment No. 14,” August 11, 2000, The right to the highest attainable standard of health (article 12 of the International Covenant on Economic, Social and Cultural Rights), 11 August 2000, https://www.refworld.org/pdfid/4538838d0.pdf.

[199] United Nations Economic Commission for Europe, “Convention on Access to Information, Public Participation in Decision-Making and Access to Justice in Environmental Matters (Aarhus Convention),” 25 June 1998, https://www.unece.org/fileadmin/DAM/env/pp/documents/cep43e.pdf. The Aarhus convention currently has 39 signatories and 47 parties.

[200] The notion of “humanitarian governance” includes this language in the context of hostilities. See, e.g., Sue Lautze, et al., “Assistance, protection, and governance networks in complex emergencies,” The Lancet 364, 9451, December 2004, https://www-sciencedirect-com.ezproxy.cul.columbia.edu/science/article/pii/S0140673604175557?via%3Dihub

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