Originally published by Yale Medicine Magazine 2022 Issue 168, “More than skin deep”. Article written by Sumaiya Sayeed.

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Of the many reasons to leave one’s home country for a new life elsewhere, war, natural disaster, and violent political or religious persecution are among the worst. For those displaced individuals who have sought a better life in the United States, it can be dispiriting to encounter new barriers: separation from families; crowded detention centers riddled with COVID-19 outbreaks; and seemingly never-ending delays to obtaining legal asylum.

The Yale Center for Asylum Medicine (YCAM), directed by Katherine C. McKenzie, MD, does what it can to alleviate the suffering of asylum-seekers. The faculty members of YCAM use clinical expertise to conduct forensic evaluations, documenting physical and psychological scars people may have acquired before or during their flight to the United States, and write affidavits that outline these findings for use in immigration court. These medical affidavits play a key role in successful legal cases for asylum. In fact, a study showed that asylum-seekers who underwent a medical evaluation were granted asylum at a rate of 89% compared with 37.5% for those who had not.

At YCAM, asylum-seeking individuals are referred to as clients rather than patients, as the clinicians do not provide medical care. These forensic evaluations are performed to produce objective evidence of torture or ill treatment that can be presented in immigration court. In the past year, YCAM has evaluated 17 clients with the help of seven faculty members and 15 students at Yale School of Medicine (YSM) and the School of Nursing.

These medical affidavits play a key role in successful legal cases for asylum. In fact, a study showed that asylum-seekers who underwent a medical evaluation were granted asylum at a rate of 89% compared with 37.5% for those who had not.

Students who assist YCAM faculty members typically review clients’ declaration (in which they describe physical or psychological wounds and their origins) in advance, ask questions during the interview, and photograph or document physical scars. The scars are described, and consistencies with their alleged causes are documented in accordance with the Istanbul Protocol, a set of international guidelines for documenting torture and its consequences adopted by the United Nations in 1999.

“One client I saw had been tortured with electrocution, leaving them with permanent raised scars on their chest and neck. They shed tears throughout the retelling of their trauma; but after some long pauses and breaks, they persisted, knowing the importance of the medical evaluation in obtaining asylum,” said Rachel Levinson, a medical student at YSM. (Pronouns have been changed to protect the client’s privacy.)

Each client’s story is different, as is every client’s reaction: many show distress or sadness, while others exhibit a flat affect. Often the greatest challenge is anticipating and accommodating the emotional difficulties that a client may experience. “YCAM has taught me the importance of establishing trust with our clients, as it is incredibly triggering to talk about trauma. Learning how to ask the right questions in a trauma-informed way is a skill I am constantly building upon and will continue to sharpen throughout my career,” Levinson said. After the evaluations, the student and faculty member compose a legally valid medical affidavit for the client’s attorney.

“YCAM has taught me the importance of establishing trust with our clients, as it is incredibly triggering to talk about trauma.”

Rachel Levinson, a medical student at YSM

YCAM periodically hosts a training conference for clinicians and students to disseminate information about conducting evaluations of asylum-seekers. In late October 2020, this conference was presented in collaboration with the Society of Refugee Health Care Providers and drew attendees (virtually, due to pandemic restrictions) from across the United States and Canada.

In January 2021, McKenzie and collaborators from other institutions—Hope Ferdowsian, MD, MPH, and Shawn Sidhu, MD—launched the Society of Asylum Medicine (SAM), a broader organization with national scale and scope.

“They had all been doing this advocacy work for asylum-seekers for years, but as they joined forces, they found unmistakable strength and efficiency in working together,” said Niroop Rajashekar, a medical student at YSM. SAM’s main goal is to share resources, educate, and build a community for the professionals and trainees involved in this work. Rajashekar provided essential assistance to group members as they set up the SAM website, key to creating a centralized space in which collaborators in the field can share information and best practices. Beyond being the first organization involved in advocacy work for asylum-seekers to collect training videos, guidelines for medical professionals, and emerging news in one location, SAM has engendered an online community of like-minded individuals comprising medical professionals, mental health care providers, medical students, lawyers, and others.

This year, YCAM collaborated with Physicians for Human Rights (PHR) and the American Civil Liberties Union (ACLU) to research and report on the practice of force-feeding hunger strikers. Together with PHR and ACLU experts, McKenzie and two Yale medical students, Sumaiya Sayeed and John Andrews, detailed the force-feeding taking place in U.S. Immigration and Customs Enforcement (ICE) detention centers. The full report, “Behind Closed Doors: Abuse and Retaliation Against Hunger Strikers in U.S. Immigration Detention,” incorporates information from emails, case records, and interviews pertaining to hunger strikers, many of whom experienced force-feeding and other forms of retaliation while under ICE detention.

“Physicians have the authority to aid asylum-seekers on their legal pathway and a moral obligation to do no harm,” said Andrews. “One of the most startling and disappointing findings of this report was the revelation that some physicians misused their authority to enable force-feeding.” The report calls on medical professionals to advocate for protections for asylum-seekers in detention centers, and to condemn health care workers who may be complicit in involuntary medical procedures and other human rights violations.

The report includes narratives of formerly detained individuals. Their stories, as well as those in the affidavits recorded by YCAM, offer powerful testimony of the ways governments and groups can perpetuate harm against minority populations and individuals.

Creating a space for asylum-seekers to share their stories of persecution relies on the unrelenting passion and clinical skills of YCAM faculty and trainees alike. That YCAM is able to elicit harrowing narratives while providing diligent and objective documentation fulfills its core mission. YCAM continues to expand every year and includes health professionals from the specialties of general internal medicine, gynecology, pediatrics, psychology, and psychiatry. YCAM has adapted both medical and psychological evaluations to safely accommodate clients, faculty, and trainees during the COVID-19 pandemic.

The Syrian government has targeted health care workers with detention, abuse, and torture. Here are some of their stories.

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Introduction

On February 1, 2021, the Myanmar military (Tatmadaw) took control of the country in a coup d’état.^[1] Hundreds of thousands of people took to the streets in protest.^[2] The military regime not only imprisoned political rivals and dissenters,^[3] but quickly proceeded to wage war against the people of Myanmar at large with excessive force against protesters,^[4] arbitrary arrests of civil servants and other civilians, and indiscriminate attacks on entire communities across the country.^[5] The Civil Disobedience Movement (CDM), led by civil servants, grew into nationwide strikes across government and private sectors. For their early leadership and broad participation in CDM, health care workers have been targeted by the military with hundreds of arrest warrants for doctors and nurses as well as arrests of health care workers at their jobs and homes.^[6] Attacks on health care workers and health care itself has become a prominent feature of the coup d’état.^[7] Today, Myanmar is one of the most dangerous places in the world to be a health care worker.^[8]

Attacks on health care workers and health care itself has become a prominent feature of the coup d’état. Today, Myanmar is one of the most dangerous places in the world to be a health care worker.

Hospitals and other health care facilities have been occupied,^[9] raided, and shot at by Myanmar security forces;^[10] health care workers have been arbitrarily beaten and arrested while providing care;^[11] and patients have been arrested while receiving treatment in facilities. Myanmar military have occupied hospitals and used them as military bases, in direct violation of international humanitarian law.^[12] Myanmar security forces have raided and taken medical supplies from private clinics and charity organizations focused on providing voluntary medical and social assistance, including those associated with religious organizations,^[13] and have warned them not to provide care to civilian protesters.^[14] Humanitarian aid, including medical supplies, to displaced populations has been blocked by the Myanmar military.^[15] The country was devastated by a disastrous third wave of COVID-19 from July to September 2021.^[16] Thousands of people died – mostly at home, without access to any health care facility or provider – due to the collapse of the public health care system and obstruction of health care access.^[17]

Hospitals and other health care facilities have been occupied, raided, and shot at by Myanmar security forces; health care workers have been arbitrarily beaten and arrested while providing care; and patients have been arrested while receiving treatment in facilities.

The country’s conflict landscape has changed dramatically with widespread opposition to the coup d’état, including from long-established ethnic armed organizations and newly formed armed forces.^[18] The Myanmar military has shelled residential neighborhoods with artillery, burning down homes, cutting off internet access and food supplies, and indiscriminately shooting civilians. This heavy-handed retaliation against opposition to the coup has displaced more than 296,000 women, men, and children since February 1, adding to already significant numbers of internally displaced people across the country and expanding the geographical areas of displacement (e.g. northern Chin state, Magway region, and Sagaing region).^[19] Thousands of people have fled across borders to India and Thailand, including almost an entire community of 12,000 people from Thantlang township, Chin state.^[20] With indiscriminate attacks on communities and blocking of humanitarian aid by the Myanmar military, humanitarian organizations face safety challenges in accessing  conflict areas and displaced populations, including across affected areas that have not seen conflict in recent years or needs on this scale before. ^[21]

Under international human rights and humanitarian law, states are obligated to ensure effective protection for health care workers at all times, and to provide unencumbered access to emergency health care for all.^[22] The people of Myanmar are facing gravely diminished access to routine and emergency health care services, with ongoing and egregious deliberate targeting of health care by the Myanmar military and other armed actors opposing the coup d’état.

Political Context

On February 1, 2021, the Myanmar military (Tatmadaw), led by Senior General Min Aung Hlaing, contested the results of the November 2020 general elections, where the National League for Democracy, the party led by Aung San Suu Kyi, won by a large margin. The Myanmar military arrested leaders of the newly elected government and declared a state of emergency in which the military would control the country under a caretaker government for at least a year.^[23] Widespread peaceful protests quickly erupted throughout the country and military security forces responded to the protests with brutal crackdowns and excessive force, using rubber bullets, live ammunition, tear gas, and water cannons against non-violent demonstrators, and shooting both medical aid volunteers and children.^[24]

“Our healthcare workers are working in fear. We are being oppressed, we are forcefully arrested – as are our family members if we cannot be found – and are being prevented from providing proper medical care, resulting in permanent damage to patients and the loss of many lives.”
Mandalay Medical Cover (Partner Statement to UN Human Rights Council)

Newly organized militias formed in opposition to the coup d’état and attacks on communities, mostly notably as part of the People’s Defence Force (PDF) under the National Unity Government (NUG), which was created by a group of elected lawmakers and members of parliament who oppose the coup d’état and military-led State Administration Council (SAC)’s self-declared caretaker government.^[25] The NUG has declared its intention to form a Federal Union Army, which would include ethnic armed organizations that have fought against the Myanmar military for decades.^[26] In a speech on September 7, the NUG’s acting president called on all citizens to “revolt against the rule of military terrorists” and declared Myanmar to be under a state of emergency until “the resumption of civilian rule in the country.”^[27] Some ethnic armed organizations and PDFs have begun to collaborate against the Myanmar military, but the extent of formal alliances and coordinated chains of command that have been or will be developed are uncertain.^[28] In the context of escalating armed resistance that has increasingly harmed civilians, the chair of the Kachin Independence Organisation called on civilian resistance groups to stop all attacks on civilians and public facilities, including schools and hospitals.^[29]

Methodology

Since February 2021, researchers from the Center for Public Health and Human Rights at Johns Hopkins University, Insecurity Insight, and Physicians for Human Rights, as part of the Safeguarding Health in Conflict Coalition, have monitored open-source digital materials, including local, national, and international news outlets, social media reports, and communications from partners to identify reports of incidents of violence against health workers, facilities, and transport as well as obstruction of health care in Myanmar. This open-source methodology follows a protocol informed by the Berkley Protocol on Digital Open Source Investigations. Incidents are categorized under commonly reported concerns such as: health workers arrested, raids on hospitals, military occupations of hospitals, health workers injured, health workers killed, and incidents impacting COVID-19 response measures. The incidents reported are neither a complete nor a representative list of all incidents. Data collection is ongoing and data may change as more information is made available. Incidents have not undergone verification, but available information is reviewed for evidence of credibility.

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Overview of Attacks on Health Care

A total of 415 attacks on health care have been documented since the start of the coup d’état on February 1, 2021. Attacks on health care for this report’s analysis include attacks on health care workers, infrastructure, and supplies. While the highest number of incidents were documented in March 2021, there has been a gradual increase in documented incidents from September 2021 through early January 2022. The incidents referred to are available on the Humanitarian Data Exchange (HDX) and are tracked on Insight Insecurity’s global map. Incidents have occurred all over the country, with notable clusters of events in the major urban areas of Mandalay and Yangon; Magway and Sagaing regions; Chin, Kachin,  Karen, and Karenni states. Incident trends have evolved alongside the wider events happening throughout the country, such as the nationwide protests, CDM, third wave of COVID-19, and declaration of the people’s defensive war. These trends will be described in more detail below.  

A total of 415 attacks on health care have been documented since the start of the coup d’état on February 1, 2021…. It is clear that health care workers are being targeted.

Attacks on Health Care Workers

Health care workers have been under attack since the beginning of the coup d’état. Attacks on health care workers include arbitrary arrests, detentions, and violence committed against all types of health care workers, ranging from doctors and nurses to emergency medics and volunteers.

A total of 125 incidents of arrest or detention, with a total number of 286 health care workers affected, have been documented from open sources since February 1, 2021. The difference between the number of arrest or detention incidents and the number of people affected reflects the fact that health care workers are often arrested en masse. According to data gathered by the Assistance Association for Political Prisoners^[30], a total of 596 health care workers (out of a total of 1966 people) are actively evading arrest warrants; 132 health care workers have been arrested (50 have since been realized); 82 health care workers remain in detention as of January 10, 2022. At least 25 doctors have been charged with high treason, colluding with an illegal organization, and incitement.^[31] Thirty health care workers have been killed since February 1, 2021.

The reports of health care workers arrested in our dataset include arrests that have been made with or without warrants, as well as other incidents of health care workers being detained. It is often difficult to differentiate between arrests and detentions, as routine procedures are often not followed. Additionally, these events are often not reported in the media, as this can reportedly make it more difficult for family members or others to advocate for the release of a person arrested or detained.

Information is more often shared on social media, although posts are sometimes taken down at the request of family members. Arbitrary arrests and detainments of all types and lengths have a harmful impact on health care workers and the provision of health care, so all such reports are included in our dataset.

Over the past twelve months, trends in attacks on health care workers have evolved. Initially, attacks primarily involved Myanmar security forces taking action against health workers participating in nationwide protests, the Civil Disobedience Movement, and the provision of medical care to injured protesters and bystanders.^[32] Overtime health care workers believed to have ties to the NUG or PDFs were targeted, including during raids of health facilities and charity organizations accused of aiding injured PDF members or supporters. Attacks by other armed actors on health care workers have emerged, particularly against those who have continued or returned to their civil servant roles and have reportedly pressured staff participating in CDM to return to work, or are believed to be military informants. Media coverage of these events appears to be limited, but such attacks are often reported as committed by unidentified assailants, or to a lesser extent, reported as committed by individuals associated with local PDFs. Publications by the military-led SAC report on these kinds of attacks and sometimes explicitly accuse local PDFs. Identifying who is responsible for these acts of violence is not always possible, but it is clear that health care workers are being targeted.

On January 7, 2022, the deputy director general of the SAC department of public health issued a letter demanding a list of personal details about health care workers affiliated with CDM, including those already dismissed, to be included in a report to the minister’s office.^[33] More warrants and arrests of health care workers are expected to follow. Reports are already emerging that arrests are increasingly extending beyond doctors and nurses to include other health care workers who provide basic health care services at local levels across the country.

Security Forces Intimidate and Kill Medics Providing Care to Protesters

On February 27, 2021, Myanmar security forces intimidated the health care workers at a medical base which provided emergency care for protesters in Sanchaung township, Yangon.^[34] On March 22, 2021, security forces shot and killed two volunteer medics while they were tending to injured protesters at the Myayee Nanda Housing Estate in Mandalay. On March 28, 2021, security forces shot and killed 20-year-old nursing student Thinzar Hein while she was providing aid to injured protesters in Monywa, Sagaing region.^[35]

Police Arrest Celebrated Health Care Humanitarian

On March 12, 2021, police arrested Dr. Than Min Htut, superintendent of Pathein Hospital and recipient of the 2010 “Citizen of Burma Award” for his humanitarian work. When residents across Pathein organized night protests calling for his release, security forces used stun grenades and rubber bullets to quash the protests.^[36] Dr. Than Min Htut was among the few government employees who was eventually granted amnesty and released from prison in August 2021.^[37]

Violent Home Arrests End with Death in Prison

On June 13, 2021, Dr Maung Maung Nyein Tun and his wife, Dr Swe Zin Oo, were beaten and arrested by the Myanmar military from their home in Maha Aungmyay township, Mandalay under charges of having ties with the NUG. They were charged with high treason under Section 17(1) of the Unlawful Association Act and Section 124 of the Penal Code. Dr. Maung Maung Nyein Tun served the government as a surgeon and a lecturer at University of Medicine, Mandalay. While detained in Obo Prison, he reportedly caught COVID-19 and was transferred to Mandalay General Hospital on July 28, where he died on August 8. He was 45 years old. His wife reportedly also caught COVID-19 in the prison.^[38]

Doctors Arrested While Providing Emergency COVID-19 Care

On July 19, 2021, SAC troops called a volunteer medical teleconsultation team under the guise of seeking a home visit for critically ill COVID-19 patients. Three doctors paid a home visit to the presumed patients in South Okkalapa township, where they were arrested. The SAC troops then went to the office of the consultation team and arrested two more doctors.

Nurse Shot by Unidentified Assailants at Private Clinic

A nurse named San Thida was shot dead on November 5, 2021 at around 10:15 a.m. in Parami Clinic in Hlaingthaya township, Yangon region. A witness reported, “The shooter(s) acted as if they were about to purchase medicine, then shot the nurse. The shooter(s) managed to escape after the incident.”^[39]

Health Care Workers and Patients are Arrested from Charity Clinic

On November 22, 2021, SAC military and police raided the charity clinic Karuna Dispensary Loikaw Diocese in Loikaw, Karenni state. Eighteen health care workers were arrested, including doctors and nurses. The 48 in-patients being treated at the clinic – seven of them with confirmed COVID-19 cases – were told to relocate to another hospital.^[40]

“The SAC has claimed they are trying to arrest Civil Disobedience Movement (‘CDM’) doctors who have shown defiance against the junta and are ‘breaking the law.’ However, many of these violent events involve private doctors who have never worked in government hospitals, volunteer doctors, NGOs and charity clinics that have been filling the gap in healthcare. As such, it is difficult to believe anything other than that healthcare workers as a whole are being deliberately targeted because they are among the first to protest against the coup d’état.”
Myanmar Doctors for Human Rights Network (Partner Statement to UN Human Rights Council)

Township Medical Superintendent Shot in the Head by Unidentified Assailant

On December 14, 2021, at around 7 p.m., Dr Wint Wint Myaing was shot dead while returning back to Kutkai town after a field visit to administer COVID-19 vaccinations. The unidentified perpetrator stopped the doctor’s car, asked her to get out, shot her multiple times in the head, then told the driver and other health staff in the car to leave the scene in the direction they had come from. Dr. Wint Wint Myaing was not a participant in the CDM and had worked for 20 years as the township medical officer of Kutkai Township Hospital.[41]

Charity Organization Ambulance Attacked by Armed Forces

On December 15, 2021, at around 1:30 a.m., an ambulance belonging to a social aid organization was attacked in Falam township, Chin state, allegedly by armed members of the Chinland Defence Force (CDF); the patient, an irrigation department official, was kidnapped and the ambulance driver sustained gunshot wounds. CDF troops later entered the hospital where the driver and other passenger were taken and confiscated their mobile phones.^[42]

Attacks on Health Infrastructure and Supplies

Attacks on health care infrastructure and supplies include actions that damage or destroy health care infrastructure and supplies as well as actions that obstruct patients from seeking care or health care workers from providing care in health facilities (including charity run clinics, temporary COVID-19 treatment centers, and emergency medic posts) by violence or threat of violence. These kinds of attacks also include actions that obstruct the safe transport of patients or medical supplies as well as the raiding of medical supplies by violence or threat of violence.

Health facilities have been occupied, raided, and shot at over the past year. During the nationwide protests, Myanmar security forces were stationed at public health facilities to wait for injured protesters seeking medical care in order to arrest them.^[43] Security forces also raided private hospitals to find and arrest health care workers participating in CDM as well as protesters receiving treatment.^[44] Security forces have occupied hospitals in urban areas before major protests^[45] and have used health facilities in remote areas as shelter. They have taken supplies, damaged health facilities with indiscriminate shooting, and arrested health care workers, forcing patients to seek care elsewhere. Ambulances have also been used by Myanmar military for transport of forces and attacks on civilians.^[46] These incidents have disrupted the delivery of medical services, hindered access to medical care and the ability of people to seek health care services without fear.

Patients Forced Out of Public Hospital

On March 12, 2021, armed security forces forcibly evacuated all hospitalized patients (approximately 30 people) in Hakha Township Hospital and ordered all hospital staff affiliated with the CDM out of the hospital. At least one patient is reported to have died after being forcibly removed.^[47]

Charity Group Offering COVID-19 Treatment Raided and Staff Arrested

On July 19, 2021 in North Dagon township, Yangon, armed SAC forces raided the offices of a charity group offering COVID-19 treatment and arrested two physicians. They also seized oxygen tanks, medication, and personal protective equipment.^[48]

Security Forces Deny Patients in Ambulance Entry to Hospital at Gunpoint

On July 17, 2021, Myanmar military forces occupying North Okkalapa Hospital in Yangon city forcibly turned back at gunpoint an ambulance carrying COVID-19 patients.^[49]

Public Hospital Attacked by Unidentified Assailants

On September 23, 2021, at around 6:30 p.m., unidentified perpetrators set off bomb at Lone Khin Hospital, a public hospital in Lone Khin village, Hpakan township, Kachin state. This followed an earlier bomb blast on September 5 at the same hospital. The hospital had not been used for routine medical services since March 2021, but was being used as a site for COVID-19 vaccinations. No injuries or causalities were reported.[50]

Station Hospital Occupied and Medical Equipment Stolen

On November 16, 2021, at around 4 p.m., Border Guard Forces (an armed force under the command of the Myanmar military) raided a station hospital in Pa-Lun-Taung village, Hpa-An township, Hpa-An district, Karen state. Windows were broken, the building was occupied, and the public was threatened not to enter the compound. Medicines and hospital equipment were stolen.^[51]

“In March, the Myanmar military took control of the majority of public hospitals, endeavoring to reopen them using military personnel. However, the stationing of troops inside the hospital compounds caused many civilians to fear seeking care there.”
Mandalay Medical Cover (Partner Statement to UN Human Rights Council)

Health Facilities Destroyed

Myanmar military attacks continue to damage health facilities, including the Kathea Village Sub Rural Health Centre^[52] and the Pekon Rehabilitation Center, both in Pekon township, Shan state.^[53]

Attacks on Health Care Exacerbate Disastrous Third Wave of COVID-19

The military coup d’état has exacerbated the dire COVID-19 situation in Myanmar by disrupting vaccination rollout and hospital capacity improvement, destroying public trust and support for the implementation of prevention measures, and obstructing public access to lifesaving medical supplies and health facilities. Local media reports documented the devastating impacts of the COVID-19 “third-wave” (July – September 2021) with an unprecedented surge in deaths, which overwhelmed crematoriums and cemeteries.^[54] While local officials were able to respond to the first and second waves of COVID-19 with the strong support of the public, lack of public trust and support contributed to the military’s flailing response to the third wave.^[55]

Myanmar survived the first wave of COVID-19 with relatively little harm, reporting 374 cases and six deaths from late March to early August 2020.^[56] Cases did not begin to rise significantly until September 2020, reaching a total of 119,788 confirmed cases and 2,532 deaths by late December 2020, according to government data.^[57] While the SAC-controlled Ministry of Health data is assumed to be under reporting total confirmed cases and deaths due to lack of adequate testing and surveillance, there has still been a dramatic increase in reported cases and deaths since February 1, 2021. By January 2022, the total number of confirmed cases stood at more than 500,000 and the total number of deaths at more than 19,000.^[58] In part, these figures reflect the military’s obstruction and/or termination of COVID-19 prevention and control measures since the start of the coup d’état. 

In late January 2021, Myanmar became one of the first southeast Asian nations to begin vaccinating its population. On January 22, it received 1.5 million doses of Covishield/AstraZeneca from India, which it began administering to health personnel, front line workers, government officials, and parliamentarians.^[59] The government ordered an additional 30 million doses from the Serum Institute of India and planned to begin vaccinating the public on February 5, starting with people at least 65 years of age.^[60] The Myanmar Ministry of Health and Sports was also in the process of improving hospital services across the country for treatment of COVID-19 with significant support from the Asian Development Bank, World Bank, and other major donors in the health sector.^[61] These efforts were largely halted by the start of the coup d’état on February 1.

Since then, vaccines have been delayed from arriving in country and have not been distributed according to previous plans to prioritize vulnerable groups. Instability resulting from the coup delayed receipt of the second shipment of vaccines from India in February 2021.^[62]The Myanmar military commandeered the meager supply that was already in the country and distributed them to soldiers and military affiliates.^[63] When and where vaccines were distributed to civilians, there was widespread hesitation, wherein people who were involved in the protests or had expressed anti-military views were fearful of military persecution at the point of vaccination delivery. Myanmar was subsequently slated to receive 27 million doses through the GAVI Alliance’s (formerly the Global Alliance for Vaccines and Immunisation) COVID-19 Vaccines Global Access (abbreviated as COVAX) program, with the first 5.5 million doses scheduled to arrive in March 2021. However, the military’s failure to demonstrate capacity to distribute vaccines led to COVAX delaying its delivery indefinitely.^[64]

It must also be acknowledged that the National Unity Government (NUG), despite several attempts at engaging the WHO and COVAX for parallel vaccine procurement, was frequently blocked due to its status as an unrecognized governing body. This was a crucial misstep in health diplomacy, as the NUG at the time was predominantly based in the so-called “liberated areas” along Myanmar’s borders, and could have distributed critical vaccines to ethnic populations through cross-border mechanisms in collaboration with Myanmar’s many highly capable ethnic health organizations. Appeals to ASEAN and the UN to coordinate a “patchwork” system of vaccine distribution to address gaps in vaccine coverage across Myanmar were largely unsuccessful.

Incidents of the military restricting access to lifesaving medical supplies, raiding charity organizations providing supplies and treatment, and blocking access to public facilities emerge as common themes during the COVID-19 third wave timeframe. Multiple reports indicated that Myanmar military appropriated private oxygen plants in Yangon and began requiring citizens to apply for oxygen at SAC offices.^[65] Similar actions were taken in other parts of the country. On July 25, 2021, the military seized an oxygen production facility in Hpakant township, Kachin state and ordered the facility to only refuel oxygen tanks provided by the military. At the time of the seizure, this facility was the only facility capable of refilling tanks in Hpakant township and more than 70 patients being treated for COVID-19 required oxygen.[66] On July 31, 2021, the SAC troops told some 1,000 civilians queuing for medicines to treat of COVID-19 at Shwe Ohh Pharmacy to go home.^[67]These attacks on health care service delivery limited access to lifesaving medical supplies and treatment even during the height of a COVID-19 third wave, thus contributing to the high rates of mortality reported.

Final allocation of vaccines through COVAX is contingent on whether they can be distributed at the required speed and scale in a neutral and impartial manner, irrespective of ethnicity, gender, socio-economic status, or political affiliation. Respect for protection of health care workers and service delivery by all armed actors will be essential to make equitable and impartial delivery of COVID-19 vaccines possible. In November 2021, COVAX committed to delivering millions of Johnson & Johnson Covid-19 vaccine doses in December to the border of Thailand and Myanmar under the COVAX humanitarian buffer, which was established to make vaccines available to people living in humanitarian emergencies due to conflict. This represents a significant step for people living in southeast border areas of the country, but much wider efforts will be needed to deliver vaccines to all who need them.

Conclusion

The impacts on the people of Myanmar of the military coup d’état and attacks on health care over this past year are incalculable and will continue to have implications for many years to come – especially as these attacks continue unabated.

Private and ethnic health facilities have experienced higher care-seeking demands, given the limited functionality of government facilities, the reluctance of many to seek services there, and the defection of government civil service health workers participating in the Civil Disobedience  Movement, who are now providing health services outside of the context of government health care system.[68] Intensified and expanded conflict, along with indiscriminate attacks on communities, have forced more health workers to resort to secret, mobile approaches to providing health care, similar to those practiced by ethnic and community-based health organizations throughout decades of conflict in border areas.[69] The poorest and those living in conflict-affected situations struggle to access any health care at all and indications of foregone care are increasing, including for routine and non-urgent chronic conditions. Population-level increases in morbidity and mortality are expected with the limited level of routine immunization services and other essential health care services available, thus contributing to an ever-increasing health crisis in the country.

In addition to the direct impacts of attacks on health care, which prevent people from accessing lifesaving health interventions and seeking care without fear, the wider implications of the coup d’état are having a grave impact on health and well-being. The World Bank predicts an annual economic contraction in Myanmar of up to 18 percent for this year and a recent United Nations Development Programme analysis has warned that half of the country’s population could be living in poverty by early 2022.[70]  More than 60 percent of households have reported that their health care access has worsened since the start of the coup and a third of households have reported reducing food consumption.[71] The Global Humanitarian Overview has estimated that humanitarian assistance financing requirements have more than doubled since 2021 (from 276.5 to 826 million USD), reflecting the need for wider response plans as well as the challenges of inflation and increased costs of service delivery.^[72]Given the trajectory of events at this time, including escalating conflict, increasing numbers of internally displaced people and refugees, and the effective collapse of the public health care system, there is no end in sight to this human rights and health crisis for the people of Myanmar.

“We are determined to continue working until medical personnel can provide required medical care to wounded protesters, the sick, and the injured, freely in each and every corner of Myanmar.”
Myanmar Doctors for Human Rights Network (Partner Statement to UN Human Rights Council)

Recommendations

Health care workers have the obligation and right to treat those in need – regardless of politics, race, or religion – under all circumstances of peace and conflict. Attacks on health care workers violate human rights and are grave breaches of international law. Members of the international community have made commitments to carrying out the requirements of UN Security Council Resolution 2286, which strongly condemns attacks on medical personnel in conflict situations.^[73] Many states have formally reiterated their commitments to principles of the Geneva Conventions, including through the July 2019 Call for Action to strengthen respect for international humanitarian law and principled humanitarian action, which was signed by more than 50 states.^[74]

Protection of health care workers, health care services and humanitarian access to all populations in need must be respected and supported by all actors in Myanmar. International actors should also support the urgent need for COVID-19 vaccines, care and broader humanitarian support to the people of Myanmar through flexible mechanisms that recognize the evolving nature of conflict dynamics and difficulty in reaching all people in need. This should include support for cross-border delivery of humanitarian aid (along borders with China, India and Thailand) to reach those in need who cannot be reached otherwise.

 

To the State Administration Council and Tatmadaw:

• Adhere to the provisions of international humanitarian and human rights law regarding respect for and the protection of health services and the wounded and sick, and regarding the ability of health workers to adhere to their ethical responsibilities of providing impartial care to all in need; and
• Cease the targeting of health care workers with warrants and arrests for participating in the Civil Disobedience Movement and peaceful protests or for their provision of health care; immediately release those arbitrarily detained.
• Provide the United Nations, national and international aid organizations safe, sustained and unfettered access to all areas with internally displaced population in Myanmar.
• Cooperate with COVAX to provide equitable access to COVID-19 vaccines to all people in Myanmar, including those to be reached by ethnic and community-based organizations, non-governmental and UN organizations.

To the National Unity Government, Ethnic Armed Organizations and People’s Defence Force:

• Adhere to the provisions of international humanitarian and human rights law regarding respect for and the protection of health care workers, health care services, the wounded and sick as well as the ability of health care workers to fulfill their ethical responsibilities of providing impartial care to all in need.
• Serve and protect Myanmar civilians irrespective of political affiliation, and refrain from fomenting divisions among civilians as it relates to universal matters of health.
• Respect mandates for humanitarian access to all populations in the country.

To the International Community:

• Urge the Tatmadaw and military regime in Myanmar to adhere to the provisions of international humanitarian and human rights law regarding respect for and the protection of health care workers, health care services, the wounded and sick as well as the ability of health care workers to fulfill their ethical responsibilities of providing impartial care to all in need.
• Ensure the full implementation of Security Council Resolution 2286 and adopt measures to enhance the protection of and access to health care in situations of armed conflict as set out in the Secretary-General’s recommendations to the Security Council in 2016.
• Support thorough, impartial, and independent investigations into alleged violations of obligations to respect and protect health care and for the prosecution of the alleged perpetrators of such violations.
• Facilitate the unhindered delivery and distribution of COVID-19 vaccines in areas of armed conflict, as called for in UN Security Council Resolution 2565.
• Support COVAX for the delivery of COVID-19 vaccines to all people in Myanmar and other initiatives to ensure sufficient COVID-19 tests, therapies, and related supplies.
• Increase support to meet growing humanitarian needs, including through cross-border delivery of humanitarian aid (along borders with China, India and Thailand) to reach those in need who cannot be reached otherwise.

“One day without adequate health care is one more day with unnecessary and preventable deaths. The people dying are not just nobodies. They are our country’s future generations, parents of these children, and people that are contributing to the country in their own able ways. As such, it is important for these people to get medical care without any fear and for medical professionals to provide the care whenever and wherever needed…. By effectively and forcibly preventing doctors from providing essential medical care to these people, many lives which could otherwise have been saved are unnecessarily lost.”
Mandalay Medical Cover (Partner Statement to UN Human Rights Council)

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Acknowledgments

This report was written by an anonymous author and Lindsey Green, program officer at Physicians for Human Rights (PHR). Data was collected by staff, consultants, and volunteers at the Insecurity Insight, the Johns Hopkins Center for Public Health and Human Rights, and Physicians for Human Rights, including (in alphabetical order by surname) Helen Buck, Brian Elmore, Khin Hnit Oo, Jennifer Leigh, Sandra Mon, Nang Phoo, and Christina Wille.

The research summary was reviewed by PHR staff, including Max Hadler, COVID-19 senior policy expert; Michele Heisler, medical director; Thomas McHale, deputy director of the Program on Sexual Violence in Conflict Zones; Karen Naimer, director of programs; and Michael Payne, deputy director of advocacy. The research summary was also reviewed by Chris Beyrer, director, Center for Public Health and Human Rights at Johns Hopkins University (CPHHR), Sandra Mon, CPHHR senior research program coordinator, and Christina Wille, director of Insecurity Insight.

The research summary was edited and prepared for publication by Claudia Rader, PHR senior communications manager. Hannah Dunphy, PHR digital communications manager, managed the digital presentation.

This document is funded and supported by the Foreign, Commonwealth and Development Office (FCDO) of the UK government through the RIAH project at the Humanitarian and Conflict Response Institute at the University of Manchester, by the European Commission through the “Ending violence against healthcare in conflict” project, and by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Insecurity Insight, the Johns Hopkins Center for Public Health and Human Rights, and Physicians for Human Rights and do not necessarily reflect the views of USAID, the U.S. government, the European Commission, the FCDO, or Save the Children Federation, Inc.  

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Endnotes

[1] Russell Goldman, “Myanmar’s Coup, Explained,” The New York Times, January 10, 2022, sec. World, https://www.nytimes.com/article/myanmar-news-protests-coup.html.

[2] “Anti-Coup Mass Protests Take Place in Cities across Myanmar,” Myanmar NOW, February 7, 2021, https://www.myanmar-now.org/en/news/anti-coup-mass-protests-take-place-in-cities-across-myanmar.

[3] “Myanmar Military Detained 220 Political Prisoners Since Coup: AAPP,” The Irrawaddy, February 11, 2021, https://www.irrawaddy.com/news/burma/myanmar-military-detained-220-political-prisoners-since-coup-aapp.html.

[4] Physicians for Human Rights, “Myanmar Military Must End Excessive Use of Force against Protestors, Detention of Health Care Workers,” February 18, 2021, https://phr.org/news/myanmar-military-must-end-excessive-use-of-force-against-protestors-detention-of-health-care-workers/.

[5] Joyce Sohyun Lee et al., “How Myanmar’s Military Terrorized Its People with Weapons of War,” Washington Post, August 25, 2021, https://www.washingtonpost.com/world/interactive/2021/myanmar-crackdown-military-coup/.

[6] Physicians for Human Rights, “Myanmar Military Must End Excessive Use of Force against Protestors, Detention of Health Care Workers.”

[7] Physicians for Human Rights, “At Least 109 Reported Attacks and Threats to Health Care in Myanmar Over Just Two Months of Military’s Crackdown,” April 23, 2021, https://phr.org/news/at-least-109-reported-attacks-and-threats-to-health-care-in-myanmar-over-just-two-months-of-militarys-crackdown/.

[8] World Health Organization (WHO), “Surveillance System for Attacks on Health Care (SSA),” accessed January 19, 2022, https://extranet.who.int/ssa/Index.aspx; Jonathan Head, “Myanmar Coup: The Doctors and Nurses Defying the Military,” BBC News, January 7, 2022, sec. Asia, https://www.bbc.com/news/world-asia-59649006; Zaw Wai Soe et al., “Myanmar’s Health Leaders Stand against Military Rule,” The Lancet 397, no. 10277 (March 2021): 875, https://doi.org/10.1016/S0140-6736(21)00457-8.

[9] “Myanmar Junta Occupies Schools, Hospitals And Shutters 5 Media Outlets in Fresh Clampdown,” Radio Free Asia, March 8, 2021, https://www.rfa.org/english/news/myanmar/fresh-clampdown-03082021172256.html.

[10] “Hospitals, Clinics Not Spared Myanmar Regime Forces’ Violence,” The Irrawaddy, April 1, 2021, https://www.irrawaddy.com/news/burma/hospitals-clinics-not-spared-myanmar-regime-forces-violence.html.

[11] “Medics, Aid Volunteers Become Latest Targets of Myanmar Junta’s Brutality,” Radio Free Asia, March 4, 2021, https://www.rfa.org/english/news/myanmar/emergency-care-workers-03042021172046.html.

[12] Helen Regan, “Myanmar Military Occupies Hospitals and Universities Ahead of Mass Strike,” CNN, March 8, 2021, https://www.cnn.com/2021/03/08/asia/myanmar-military-hospitals-mass-strike-intl-hnk/index.html.

[13] Esther J, “Loikaw Church Closes Clinic after Military Arrests Medical Staff,” Myanmar NOW, November 24, 2021, https://www.myanmar-now.org/en/news/loikaw-church-closes-clinic-after-military-arrests-medical-staff.

[14] “Post by AM Htet,” Facebook, March 13, 2021, https://www.facebook.com/photo/?fbid=2956500451341728&set=bc.AbqUF94sQfCDuRPnTzshHG6uca4cTjNjLqxZAdaL2G0sC37zVsnPeztaMetdi00gsyBXHEfNUdAY8t68nks9FLRfMr0m032w4kwzKe9jurHTGSUj-_CLR1f0bMZeCzXtda574rrvrcUYDc4UpA44ZW70PTZD1Nrj2Is6HuUH0N60g3Cjpk7Bwe-D288Lkq4nacJNYrk1WrEcuLm5wuinErli45-L-gcqTDjKpTQ39_4Y45ckGH5BoHuTKnjL39lhsVxA9QI4zNNFsi9Ns9482yeLi_DgmcVQ4DCZGAKnh4nUAw.

[15] Progressive Voice et al., “Nowhere to Run: Deepening Humanitarian Crisis in Myanmar,” September 2021, https://progressivevoicemyanmar.org/wp-content/uploads/2021/09/No-Where-To-Run-Eng.pdf.

[16] “As Myanmar Regime Mishandles COVID-19, More Than 2,000 People Die in Three Weeks,” The Irrawaddy, July 21, 2021, https://www.irrawaddy.com/news/burma/as-myanmar-regime-mishandles-covid-19-more-than-2000-people-die-in-three-weeks.html.

[17] Ian Christopher Rocha et al., “Myanmar’s Coup d’état and Its Impact on COVID-19 Response: A Collapsing Healthcare System in a State of Turmoil,” BMJ Military Health, May 21, 2021, bmjmilitary-2021-001871, https://doi.org/10.1136/bmjmilitary-2021-001871; Grace Tsoi and Moe Myint, “Covid and a Coup: The Double Crisis Pushing Myanmar to the Brink,” BBC News, July 29, 2021, sec. Asia, https://www.bbc.com/news/world-asia-57993930; “COVID Cover up: Third Wave Death Toll May Be in Hundreds of Thousands,” Frontier Myanmar, January 14, 2022, https://www.frontiermyanmar.net/en/covid-cover-up-third-wave-death-toll-may-be-in-hundreds-of-thousands/.

[18] International Crisis Group, “Myanmar’s Coup Shakes Up Its Ethnic Conflicts” (International Crisis Group, January 12, 2022).

[19] UNHCR, “Myanmar Emergency – UNHCR Regional Update – 17 December 2021,” December 17, 2021, https://data2.unhcr.org/en/documents/details/90133.

[20] Sui-Lee Wee, “Thousands Flee Myanmar for India Amid Fears of a Growing Refugee Crisis,” The New York Times, October 19, 2021, https://www.nytimes.com/2021/10/19/world/asia/myanmar-refugees-india.html.

[21] Office of the United Nations High Commissioner for Human Rights, “Written Updates of the Office of the United Nations High Commissioner for Human Rights on the Situation of Human Rights in Myanmar (A/HRC/48/67),” September 16, 2021, https://reliefweb.int/report/myanmar/written-updates-office-united-nations-high-commissioner-human-rights-situation-human; Crisis Group Asia, “Taking Aim at the Tatmadaw: The New Armed Resistance to Myanmar’s Coup” (Yangon/Bangkok/Brussels: International Crisis Group, June 28, 2021).

[22] “Medical Neutrality,” Physicians for Human Rights, accessed January 19, 2022, https://phr.org/issues/health-under-attack/medical-neutrality/.

[23] Goldman, “Myanmar’s Coup, Explained.”

[24] “Medics, Aid Volunteers Become Latest Targets of Myanmar Junta’s Brutality”; Nu Nu Lusan, Kyaw Hsan Hlaing, and Emily Fishbein, “Medics Risk Lives to Treat Injured in Myanmar Anti-Coup Protests,” Aljazeera, March 3, 2021, https://www.aljazeera.com/news/2021/3/3/myanmar-medics-risk-lives-to-treat-injured-in-anti-coup-protests; Hannah Beech, “‘She Just Fell Down. And She Died.,’” The New York Times, April 4, 2021, sec. World, https://www.nytimes.com/2021/04/04/world/asia/myanmar-coup-deaths-children.html; Physicians for Human Rights, “Myanmar Military Must End Excessive Use of Force against Protestors, Detention of Health Care Workers.”

[25] Mong Palatino, “CDM, NUG, EAO and Other Acronyms of Myanmar’s Anti-Coup Resistance,” Global Voices (blog), June 3, 2021, https://globalvoices.org/2021/06/03/cdm-nug-eao-and-other-acronyms-of-myanmars-anti-coup-resistance/.

[26] Sebastian Strangio, “Can Myanmar’s New ‘People’s Defense Force’ Succeed?,” May 6, 2021, https://thediplomat.com/2021/05/can-myanmars-new-peoples-defense-force-succeed/.

[27] “Myanmar’s Shadow Govt Declares War on Military Regime,” The Irrawaddy, September 7, 2021, https://www.irrawaddy.com/news/burma/myanmars-shadow-govt-declares-war-on-military-regime.html.

[28] “NUG Establishes ‘Chain of Command’ in Fight against Regime,” Myanmar NOW, October 28, 2021, https://www.myanmar-now.org/en/news/nug-establishes-chain-of-command-in-fight-against-regime; International Crisis Group, “Myanmar’s Coup Shakes Up Its Ethnic Conflicts.”

[29] “KIO Chair Warns Resistance Groups About Attacking Civilians,” Kachin News Group (KNG), January 4, 2022, https://kachinnews.com/2022/01/04/kio-chair-warns-resistance-groups-about-attacking-civilians/.

[30] “AAPP | Assistance Association for Political Prisoners,” AAPP | Assistance Association for Political Prisoners, accessed January 20, 2022, https://aappb.org.

[31] “Former Head of Covid-19 Vaccine Rollout Charged with High Treason,” Myanmar NOW, June 16, 2021, https://www.myanmar-now.org/en/news/former-head-of-covid-19-vaccine-rollout-charged-with-high-treason.

[32] Nu Nu Lusan, Kyaw Hsan Hlaing, and Emily Fishbein, “Medics Risk Lives to Treat Injured in Myanmar Anti-Coup Protests.”

[33] Khit Thit Media, “Khit Thit Media 1/8/22 Facebook Post,” Facebook, January 8, 2022, https://www.facebook.com/khitthitnews/posts/1396506550786687.

[34] The Irrawaddy, “Riot Police Indiscriminately Intimidated and Arrested Bystanders after Cracking down Anti-Military Regime Protesters in Yangon’s Myaynigone on Saturday. (The Irrawaddy) #WhatsHappeningInMyanmar Https://T.Co/PLtfVwOHyZ,” Tweet, Twitter, February 27, 2021, https://twitter.com/IrrawaddyNews/status/1365556852327469057.

[35] Myanmar Now, “Myanmar Now 3/28/21 Facebook Post,” Facebook, March 28, 2021, https://www.facebook.com/MyanmarNowEnglishVersion/posts/2617495638541664.

[36] “Medical Superintendent Charged for Refusing Regime’s Order to Reopen Hospital,” The Irrawaddy, March 14, 2021, https://www.irrawaddy.com/news/burma/medical-superintendent-charged-refusing-regimes-order-reopen-hospital.html.

[37] “Myanmar’s Junta Releases Jailed Anti-Coup Activists And Government Employees,” Radio Free Asia, August 2, 2021, https://www.rfa.org/english/news/myanmar/release-08022021165542.html.

[38] “Myanmar Surgeon Arrested by Junta Dies After Contracting COVID-19 in Prison,” The Irrawaddy, August 9, 2021, https://www.irrawaddy.com/news/burma/myanmar-surgeon-arrested-by-junta-dies-after-contracting-covid-19-in-prison.html.

[39] DVB, “လှိုင်သာယာတွင် သူနာပြု ဆရာမ ၁ ဦး ပစ်သတ်ခံရ,” November 5, 2021, http://burmese.dvb.no/archives/498537; Mizzima, “Mizzima – News in Burmese 11/5/21 Facebook Post,” Facebook, November 5, 2021, https://www.facebook.com/MizzimaDaily/posts/4942675189100680.

[40] Myanmar Labour News, “Myanmar Labour News Facebook Post,” Facebook, November 24, 2021, https://www.facebook.com/myanmarlabournews/posts/679018526817208 “စစ်တပ်ဝင်စီးသည့် လွိုင်ကော်ဘုရားကျောင်းဆေးခန်း ပိတ်သိမ်းထားရ“ Myanmar Now, November 23, 2021, https://www.myanmar-now.org/mm/news/9409.

[41] Shan News, “Shan News Facebook Post,” Facebook, December 14, 2021, https://www.facebook.com/shannewsburmese/posts/4656584957767244

“Kutkai Township medical superintendent shot to death,“ Eleven Media Group, December 16, 2021, https://elevenmyanmar.com/news/kutkai-township-medical-superintendent-shot-to-death.

[42] People Media, “People Media Facebook Post”; “Irrigation Dept Official Abducted On Way To Hospital In Falam.”

[43] “Wounded Myanmar Protesters Fear Arrest in Junta Hospitals,” The Straits Times, June 16, 2021, https://www.straitstimes.com/asia/se-asia/wounded-myanmar-protesters-fear-arrest-in-junta-hospitals.

[44] “Myanmar Crisis Heightens with Police Raids and Strike Call,” AP News, April 20, 2021, sec. Shootings, https://apnews.com/article/world-news-social-media-myanmar-media-yangon-aadacc0f45fb4d1a9ef2766fabf82cd6.

[45] Helen Regan, “Myanmar Military Occupies Hospitals and Universities Ahead of Mass Strike.”

[46] “ကနီတွင် စစ်တပ်က လူနာတင်ကားပေါ်မှ ပစ်၊ ရွာသားတစ်ဦးသေ” Myanmar Now, July 31, 2021, https://www.myanmar-now.org/mm/news/7644;  

 “ဆားတောင် PDF စခန်းကို လူနာတင်ယာဉ်သုံးပြီး စစ်ကောင်စီတပ် ဝင်စီး” Myanmar Now, October 19, 2021, https://www.myanmar-now.org/mm/news/8872. 

[47] The Chinland Post, March 12 – Military Deployment at General Hospital in Hakha, 2021, https://www.youtube.com/watch?v=_VeMedQDcpc.

[48] “Junta Lures, Arrests Community Doctors by Posing as Covid-19 Patients,” Myanmar NOW, July 20, 2021, https://www.myanmar-now.org/en/news/junta-lures-arrests-community-doctors-by-posing-as-covid-19-patients.

[49] DVB, “လှိုင်သာယာတွင် သူနာပြု ဆရာမ ၁ ဦး ပစ်သတ်ခံရ”; May Wong, “Seems #Myanmar #military Has Locked down North Okkalapa General Hospital in Eastern #Yangon & Not Allowing People, Including Paramedics in. Unclear What Reason Is. Hospitals Been Overwhelmed & Authorities Recently Also Requested for Medical Volunteers #WhatsHappeningInMyanmar Https://T.Co/Vp2pvdLTeW,” Tweet, Twitter, July 17, 2021, https://twitter.com/MayWongCNA/status/1416424878891175939; “Spring Revolution Daily News for 19th July 2021,” Mizzima Myanmar News and Insight, July 19, 2021, https://www.mizzima.com/article/spring-revolution-daily-news-19th-july-2021.

[50] “KO KO Jade Facebook Post,” Facebook, September 23, 2021,

https://www.facebook.com/groups/138586506772556/posts/914483715849494/.

[51] “Ministry of Health, National Unity Government of Myanmar 11/17/21 Facebook Post,” Facebook, November 17, 2021, https://www.facebook.com/MoHNUGMyanmar/posts/260774832748797.

[52] K Moe, “K Moe Facebook Post.”

[53] Nyein Swe, “ဖယ်ခုံတွင် စစ်ကောင်စီတပ်က ဆေးရုံဘက်သို့ လက်နက်ကြီးဖြင့် ပစ်ခတ်.”

[54] “Death Toll Underreported on Myanmar’s COVID-19 Frontline: Charities,” The Irrawaddy, July 8, 2021, https://www.irrawaddy.com/news/burma/death-toll-underreported-on-myanmars-covid-19-frontline-charities.html.

[55] “Junta Tries – and Fails – to Use Pandemic to Tighten Grip on Power,” Frontier Myanmar, August 13, 2021, https://www.frontiermyanmar.net/en/junta-tries-and-fails-to-use-pandemic-to-tighten-grip-on-power/.

[56] A Win, “Rapid Rise of COVID-19 Second Wave in Myanmar and Implications for the Western Pacific Region,” QJM: An International Journal of Medicine, October 23, 2020, hcaa290, https://doi.org/10.1093/qjmed/hcaa290.

[57] “MOHS Myanmar COVID-19 Surveillence Dashboard,” accessed January 20, 2022, https://www.mohs.gov.mm/ckfinder/connector?command=Proxy&lang=en&type=Main&currentFolder=%2FPublications%2FCOVID-19%2FSituation%20Report%20(CEU)%2F&hash=a6a1c319429b7abc0a8e21dc137ab33930842cf5&fileName=Sitrep%20262%20(25-12-2020)%20.pdf.

[58] World Health Organization (WHO), “Myanmar: WHO Coronavirus Disease (COVID-19) Dashboard With Vaccination Data,” accessed January 19, 2022, https://covid19.who.int.

[59] Shoon Naing, “Myanmar Prioritises Healthcare Workers as It Launches Vaccination Drive | Reuters,” Reuters, January 27, 2021, https://www.reuters.com/article/us-health-coronavirus-myanmar-vaccine/myanmar-prioritises-healthcare-workers-as-it-launches-vaccination-drive-idUSKBN29W0MS.

[60] Richard C. Paddock, “Virus Surges in Myanmar After Coup,” The New York Times, July 1, 2021, https://www.nytimes.com/2021/07/01/world/asia/covid-myanmar-coup.html.

[61] Asian Development Bank, “COVID-19 Active Response and Expenditure Support Program: Report and Recommendation of the President” (Asian Development Bank, August 24, 2020), Myanmar, https://www.adb.org/projects/documents/mya-54255-001-rrp.

[62] Shoon Naing, “Myanmar Prioritises Healthcare Workers as It Launches Vaccination Drive | Reuters.”

[63] Richard C. Paddock, “Virus Surges in Myanmar After Coup.”

[64] Richard C. Paddock; Jenny Lei Ravelo, “COVAX Allocates 17M AstraZeneca Vaccine Doses, but Details Are Hazy,” Devex, July 23, 2021, https://www.devex.com/news/sponsored/covax-allocates-17m-astrazeneca-vaccine-doses-but-details-are-hazy-100439.

[65]Civil Disobedience Movement, “We Are Not Exaggerating. The Military Is Ordering Oxygen Factories Not to Refill without Their Approval (Approval from a Local Army Commander). See the Photo below! We Need#R2P for Health Intervention. The Junta Is Content to Let People Die. #WhatsHappeningInMyanmar Https://T.Co/9iHkl0BGr0,” Tweet, Twitter, July 17, 2021, https://twitter.com/cvdom2021/status/1416316614778101761.

[66] “ဖားကန့် အောက်ဆီဂျင်စက်ရုံကို စစ်တပ်ကသိမ်းပိုက်၊ အရပ်သားများ ဖြည့်ခွင့်မရ” DBV, July 27, 2021, http://burmese.dvb.no/archives/477716?fbclid=IwAR062vMoQp1HA1nOC9vjXr4lYmIwcePF6AsQKhhPp8FADgJuGGSP6ryphtI.

[67] “ရန်ကုန်တွင် ဆေးဝယ်ရန် တန်းစီနေသူများကို ရဲက လူစုခွဲ,” Myanmar NOW, July 31, 2021, https://www.myanmar-now.org/mm/news/7648.

[68]   Jonathan Head, “Myanmar Coup.”

[69] “Treating Covid Patients in Secret Myanmar Clinics,” France 24, December 27, 2021, https://www.france24.com/en/live-news/20211227-treating-covid-patients-in-secret-myanmar-clinics.

[70] The World Bank Group, “Myanmar Economic Monitor: Progress Threatened, Resilience Tested” (World Bank Group, July 2021).

[71] UNDP, “Impact of the Twin Crises on Human Welfare in Myanmar” (UNDP, December 2, 2021), https://reliefweb.int/report/myanmar/impact-twin-crises-human-welfare-myanmar-november-2021.

[72] OCHA, “Global Humanitarian Overview 2022, Part Two Inter Agency Appeals: Myanmar,” (OCHA, December 2, 2021), https://gho.unocha.org/myanmar?fbclid=IwAR2W58DTT5YqHMOsTjMXvm6LCIOFz7jyqk_3M99gC6C45Ly-2jBH4YBEr1E

[73] UN Security Council, “Security Council Adopts Resolution 2286 (2016), Strongly Condemning Attacks against Medical Facilities, Personnel in Conflict Situations,” May 3, 2016, https://www.un.org/press/en/2016/sc12347.doc.htm.

[74] “Strengthening Respect for International Humanitarian Law,” France ONU, September 2019, https://onu.delegfrance.org/Strengthening-respect-for-international-humanitarian-law.

This research brief was prepared from information complied by Insecurity Insight, Physicians for Human Rights, and the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health based on open source data. This is an update to the original data published on April 2021 that can be accessed here, and the previous brief published in October 2021, accessible here.

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On February 1, 2021, the Myanmar armed forces (known as the Tatmadaw) seized control of the country, following a general election that the National League for Democracy party won by a landslide. Over the past 10 months, between February and November 2021, hundreds of people, including children, have been killed and many injured during nationwide Civil Disobedience Movement (CDM) protests and violent crackdowns on those opposing the coup.

Doctors and nurses have been served with warrants and arrests for providing medical care to protesters, health workers have been injured while providing care to protesters, ambulances have been destroyed, and health facilities have been raided. At least 31 health workers have been killed.

From June to September, arrests of health workers slowed and fewer hospitals were occupied as the country grappled with the third wave of COVID-19. Overall attacks on health care since February, particularly the diversion of medical supplies to military personnel, had weakened the health system to the point where it was not able to adequately provide care to civilians seeking medical attention. Health measures put in place during the third COVID-19 wave signaled that the coup leaders intended to permit access to health care only for their supporters, disrupting access to all others. Coup leaders put restrictions on the sale and importation of oxygen cylinders and arrested health care workers providing COVID-19 treatment outside of government-run facilities. During this period, COVID-19 deaths in Myanmar were among the highest in the world.

The National Unity Government and its military wing, the People’s Defense Forces (PDF), declared war against the State Administrative Council (SAC) on September 7, 2021. Following this declaration, data collected in this report shows an increase in violence against health care compared to preceding months. Hospitals and health workers have been caught in the crossfire and are increasingly the victims of indiscriminate attacks. The data indicates that the overwhelming majority of these attacks are committed by the Tatmadaw, demonstrating consistent disregard for the protection of health care in conflict and a breach of human rights and humanitarian law. Since the beginning of the coup, government forces, including the military (Tatmadaw), police forces, and government-aligned militias, have committed over 90 percent of documented attacks against health care.

In recent months, the Tatmadaw appear to be adapting tactics initially used against members of the Rohingya minority in 2016-2017 for use against communities perceived to be sympathetic to pro-democracy forces. This includes the widespread burning and destruction of civilian homes and infrastructure, including hospitals and clinics, and the indiscriminate shelling of civilian populations.

This report highlights concerns over:

• Indiscriminate artillery and arson attacks on hospitals and clinics by Myanmar government forces.
• Attacks on medical personnel associated with the People’s Defense Force (PDF) and opposition groups by government forces.
• Continuing raids and occupation of hospitals and clinics.
• Arrests of large numbers of health workers.
• Re-arrests of recently freed health workers.
• Multiple cases of prisoner deaths in detention due to medical neglect.
• Escalating attacks on local NGOs, specifically those providing aid to displaced populations in ethnic minority areas.

This report is a collaboration between Insecurity Insight, Physicians for Human Rights, and the Johns Hopkins Center for Public Health and Human Rights as part of the Safeguarding Health in Conflict Coalition (SHCC). It highlights reported incidents of violence against health workers, facilities, and transport in Myanmar between February 1 and November 30, 2021, to highlight the impact on the health system as a whole. It does not include information on violence against patients. It is drawn from credible information that is available in local, national, and international news outlets, online databases, and social media reports.

Notable Developments Since Last Report

Hospitals and Clinics

Hospitals and clinics are increasingly experiencing indiscriminate artillery and arson attacks

Artillery and arson attacks are wielded against communities perceived to be sympathetic to pro- democracy forces. Since the last report in October 2021, at least four facilities were destroyed and three additional facilities damaged in fighting and indiscriminate attacks against civilians. Three of these incidents occurred in the context of heavy fighting in Pekon township, Shan state. Hospitals and clinics were also affected in Chin and Kayin states, and Mandalay and Yangon regions. For example:

• On October 1, a charity clinic and nine houses were set on fire by SAC forces in Mandalay region in a suspected retaliation attack for the assassination of a military administrator the night before in the area. Two civilians were also abducted.

• On October 26, the Pekon Rehabilitation Center, a drug rehabilitation center, was indiscriminately shelled by SAC forces during fighting with the PDF and the Karenni National Defence Force (KNDF). During the attack, displaced civilians sheltering inside the hospital were forced to flee.

• On October 29, a private clinic in Thantlang township, Chin state, was burned to the ground by SAC forces, along with at least 160 homes.

Hospitals and clinics continue to be raided or occupied by SAC forces

During the months of October and November, SAC forces raided at least 13 health facilities in Ayeyarwady, Magway, Sagaing, and Yangon regions, and Chin, Kachin, and Kayah states, resulting in the arrest of 19 health workers. This represents an escalation from the three-month period of July to September, in which eight facilities were raided or occupied. Raids on hospitals or clinics included:

• On October 2, SAC forces raided a hospital in Monywa township, Sagaing region. This occurred during an attack on the civilian population of the town, leading to the destruction of housing and arrests of civilians.

• On October 7, SAC forces entered Pyay Hospital in Pyay township, Bago region and arrested a staff member.

Health facilities are routinely occupied to gain a military advantage or detain civilians. For example:

• On October 12, SAC forces stationed themselves overnight in a hospital during an attack on Lumbang village, Chin state, firing on households and looting private property.

• On November 16, a station hospital in Kayin state was occupied and ultimately destroyed by Border Guard Forces, a local militia aligned with the government. Doctors and nurses had fled the facility in anticipation of the attack.
• On November 16, approximately 40 SAC soldiers and aligned non-state security actors occupied two sub-rural health centers in Ngwe-twin village and Thit-kyin-gyi village, Sagaing region and were seen transporting boxes of weapons into the clinic.

Health Workers

New reports of mass arrests of health workers

In November, at least 80 health workers were arrested or detained, more than in any month since the beginning of the coup. This escalation is largely due to an increase in mass arrest events, which were frequent in the months following the coup, but declined during the wave of COVID-19 infections. Mass arrests took place during coordinated home raids and at health clinics. In most arrests, health workers have been accused of aiding injured PDF soldiers or being affiliated with the CDM.

Mass health worker arrests included:

• On November 2, ten volunteers with a local NGO that delivered COVID-19 aid were arrested by SAC forces.

• On November 22, a clinic located in a Catholic church in Kayah state was raided by about 200 armed military and police forces, who accused it of being affiliated with the CDM. Eighteen health care workers were arrested and 39 patients receiving treatment at the clinic, including four COVID-19 patients, were forcibly transferred to Loikaw General or Loikaw Military Hospital. The detainees were released on November 23.

Health workers arrested or detained by SAC forces: What is known about their status?

Since the beginning of the coup, at least 284 doctors, nurses and other health professionals are reported to have been served with warrants and arrests.

On October 18, the SAC announced the pardon of 1,316 political prisoners and the dropping of charges against 4,320 political prisoners. However, more than 100 released prisoners were re-arrested shortly after their release. For example, in the Bago region, a male doctor who was released on October 18 as part of the amnesty was rearrested on October 19.

According to the Assistance Association for Political Prisoners, only six health workers, including doctors, a radiologist, and a dentist who were detained or charged with violating penal code 505a, have so far been released as part of this amnesty. All had been held for at least four months. Political prisoners detained at Insein Prison continue to report systemic denial of medical care, which has resulted in disease outbreaks and the deaths of several inmates.

Reports of attacks on military medical personnel aligned with the PDF

The escalation of the conflict has seen increased attacks on medical personnel aligned with the People’s Defense Force (PDF) providing care to civilians. In remote regions of the country with limited access to health care, medical personnel affiliated with local militias often provide primary care to civilian populations. For example:

• On November 16, eight female medics were arrested in a raid by SAC forces on a PDF outpost in Na Gar Bwet village, Kalay township, Sagaing region. The body of an additional medic was later found bearing signs of an execution-style killing at close range.

Health Providers

Escalation in attacks on local NGOs, specifically those providing aid to displaced populations in ethnic minority areas

Delivery of humanitarian aid, including medical supplies, depends on a range of local and international organizations in Myanmar. These organizations are facing ever increasing challenges in delivering essential supplies and services, including destruction of offices and raiding of supplies as well as arrests and violence against staff. There has been an escalation of attacks on these local NGOs, specifically those providing aid to displaced populations in ethnic minority regions such as Chin, Kachin, and Shan states and Sagaing region. For example:

• On November 15, a local NGO was raided by SAC forces in Mandalay. Medical supplies intended for displaced civilians were destroyed and the chairwoman of the organization was arrested.

• On November 15, an aid worker involved in supporting camps for internally displaced people was beaten and arrested by SAC forces in Pekon township, Shan state. He was reportedly killed during interrogation two days later at the 7th Military Operations Command Center in Pekon.

International NGOs and private institutions also face violence. On October 29, SAC soldiers deliberately set fire to the town of Thantlang in Chin state, leading to the destruction of more than160 homes as well as an international NGO office and a private clinic.

Recommendations

Over the past five years, members of the international community have made many commitments to carrying out the requirements of UN Security Council Resolution 2286, which was adopted in May 2016 and strongly condemns attacks on medical personnel in conflict situations.

Many states have formally reiterated their commitments, including in the July 2019 Call for Action to strengthen respect for international humanitarian law and principled humanitarian action, which was signed by more than 40 states. Further, government leaders and humanitarian responders have called for a “COVID ceasefire” in the name of regional and global health security.

We join the UN Special Rapporteur on the situation of human rights in Myanmar in calling on the UN Security Council and all member states to invoke Resolution 2565, which demands that “all parties to armed conflicts engage immediately in a durable, extensive, and sustained humanitarian pause to facilitate the equitable, safe and unhindered delivery and distribution of COVID-19 vaccinations in areas of armed conflict.”

It is imperative that COVID-19 measures are maintained in light of the new Omicron variant and continued obstruction of healthcare delivery. The increased transmissibility of Omicron raises concerns about potential outbreaks in prisons and interrogation centers, and among displaced populations, particularly in conflict zones.

Vaccines and boosters must be made available and accessible to all civilians, be it through the government, NGO clinics, or private facilities.

All UN member states should:

• adhere to the provisions of international humanitarian and human rights law regarding respect for and the protection of health services and the wounded and sick, and regarding the ability of health workers to adhere to their ethical responsibilities of providing impartial care to all in need;

• ensure the full implementation of Security Council Resolution 2286 and adopt measures to enhance the protection of and access to health care in situations of armed conflict, as set out in the Secretary-General’s recommendations to the Security Council in 2016;

• strengthen national mechanisms for thorough, impartial, and independent investigations into alleged violations of obligations to respect and protect health care in situations of armed conflict and for the prosecution of the alleged perpetrators of such violations; and

• facilitate the unhindered delivery and distribution of COVID-19 vaccinations, medication, and supplies in areas of armed conflict, as called for in UN Security Council Resolution 2565.

Non-state actors should:

• adhere to the provisions of international humanitarian and human rights law regarding respect for and the protection of health services and the wounded and sick, and regarding the ability of health workers to adhere to their ethical responsibilities of providing impartial care to all in need; and

• sign the Deed of Commitment on protecting health care in armed conflict and ensure compliance with its principles.

Data collection

• This document was prepared from information compiled by Insecurity Insight, Physicians for Human Rights, and the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health. It is drawn from credible information that is available in local, national, and international news outlets, online databases, and social media reports.

• The incidents reported are neither a complete nor a representative list of all incidents. Most incidents have not been independently verified and have not undergone verification by Insecurity Insight, Physicians for Human Rights, or the Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health.

• All decisions made on the basis of or in light of such information remain the responsibility of the organizations making such decisions. Data collection is ongoing and data may change as more information is made available.

• To share further incidents or report additional information or corrections, please contact info@insecurityinsight.org.

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This document is funded and supported by the Foreign, Commonwealth and Development Office (FCDO) of the UK government through the RIAH project at the Humanitarian and Conflict Response Institute at the University of Manchester, by the European Commission through the “Ending violence against healthcare in conflict” project, and by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Insecurity Insight and do not necessarily reflect the views of USAID, the U.S. government, the European Commission, the FCDO, or Save the Children Federation, Inc.

Executive Summary

Destruction of the health sector is a signature of the conflict which continues to unfold in Syria. It has occurred in the context of one of the most severe humanitarian crises in the world. Physicians for Human Rights (PHR) and others have documented deliberate attacks on health care facilities and personnel during the past 10 years of this crisis, but less attention has been paid to the impact of these long years of conflict, human rights violations, and collapse of health systems on health and health care delivery.

As of November 2021, northern Syria has been divided into three main areas: one controlled by the Autonomous Administration of North and East Syria in northeast Syria, another controlled by opposition groups in northwest Syria, and the third, the Turkish-controlled areas.[1] For this report, PHR conducted and analyzed 20 interviews with health care workers and experts knowledgeable about the health sectors working in these three areas. The PHR research team coded and systematically reviewed transcripts of the interviews to identify critical themes impacting the provision of health care in each area.

In this report, PHR describes how the Syrian government’s attacks on health infrastructure in northern Syria and its attempts to impede the delivery of humanitarian aid have driven the creation of a patchwork of health systems that has produced deep disparities in access to care, effectively denying people’s right to health. Understanding this complex issue is vital ahead of the United Nations Security Council’s upcoming meeting in January 2022 to consider whether to reauthorize the last remaining border crossing in northern Syria for UN humanitarian aid, Bab al-Hawa, which provides aid to 3.4 million people alone in northwest Syria, three million of whom are considered in acute need of lifesaving assistance.[2]

The Syrian government’s failure to deliver cross-line aid to needy areas from within the country spurred the Security Council’s 2014 resolution authorizing cross-border aid from other countries through four points in the north and south. Currently, the Bab al-Hawa border crossing in northwest Syria is the only entry point open to serve the humanitarian needs of people across northern Syria. In northeast Syria, the al-Yarubiya crossing was closed in January 2020 after Syria’s longtime ally, Russia, and China vetoed renewal of cross-border operations. This has caused the near collapse of the public health care system.[3] If the Security Council fails to reauthorize the Bab al-Hawa crossing, the Syrian government would gain full control over most humanitarian aid going to the north, a potentially disastrous outcome for the 6.4 million people living in areas outside the control of the Syrian government in northern Syria.

The Syrian government’s attacks on health infrastructure in northern Syria and its attempts to impede the delivery of humanitarian aid have driven the creation of a patchwork of health systems that has produced deep disparities in access to care, effectively denying people’s right to health.

Syria’s population arguably needs a functioning health care system more than ever before. Instead, the health system is straining from a decade of deterioration. Disparities that existed between government- and non-government-held areas prior to the conflict have become entrenched. Nine in 10 Syrians live below the poverty line.[4] Areas outside of government control, which host many internally displaced Syrians, have fewer resources but significant public health problems. For example, in northeast Syria, where health resources are reportedly most scarce, 55 percent of households are reported to have at least one disabled member.[5] Health choices are increasingly driven by scarcity and conflict, with women reportedly choosing cesarean sections to minimize time spent in the hospitals, which are known to be targets of attacks. By one estimate, the percentage of cesarean sections has more than doubled since the start of the conflict in 2011.[6]

This report provides a snapshot of the state of the health care systems delivery in northern Syria from August to October 2021, the period in which PHR conducted interviews. It demonstrates that the right to health of millions of Syrians is being violated by a lack of availability, accessibility, acceptability, and quality of health care – all of which are mandated by international instruments to which Syria is a party. Furthermore, the lack of coordination among the international aid community, non-governmental organizations, and local actors overseeing health systems has greatly impacted population health, as has structural discrimination. Specifically, women and girls face a lack of gynecological and reproductive medical care because health care administrators do not prioritize these services, and people with physical disabilities face difficulty accessing repurposed buildings, let alone specialized care.   

The lack of coordination among the international aid community, non-governmental organizations, and local actors overseeing health systems has greatly impacted population health, as has structural discrimination.

This report also details the challenges northern Syrian health systems face in their response to the COVID-19 pandemic. Northern Syria is now experiencing another major wave of the disease.[7] In September 2021, the number of coronavirus cases in the northwest increased 170 percent, intensive care units were filled, and designated COVID-19 health facilities reached 100 percent capacity.[8] Major issues include the diversion of resources away from non-COVID-19 health services, limited prevention and treatment supplies, and unstable funding for longitudinal pandemic management. Additional behavioral factors include lack of public adherence to health guidelines due to misinformation, financial barriers, and apathy towards the threat of COVID-19 among Syrian civilians. Women and girls in particular face barriers to accessing COVID-19 care that effectively deprive them of care.

PHR calls on donors, humanitarian actors, and all parties to the conflict involved in providing humanitarian aid to northern Syria to uphold the right to health as provided for in the Convention on Economic, Social and Cultural Rights, as well as the right to humanitarian assistance provided in the Geneva Conventions. PHR also recommends increased collaboration between donors and the humanitarian agencies they fund with local health ministries, health directorates, and health commissions across northern Syria to increase accountability for aid distribution and emphasize the importance of providing aid that is acceptable to and considers the needs of local communities. Donors and local actors alike must address structural discrimination against vulnerable populations.

PHR calls on donors, humanitarian actors, and all parties to the conflict involved in providing humanitarian aid to northern Syria to uphold the right to health.

Key Recommendations:

To the Syrian Government and Affiliated Forces, and All Parties to the Conflict:

• Fulfil the right to humanitarian assistance as provided for in international humanitarian law; and
• Promote the right to health in areas under their control, including non-discrimination with regards to distribution and accessibility.

To UN Security Council Member States and the International Community:

• Ensure the provision of humanitarian aid through cross-border supply, the most efficient way possible to deliver assistance to millions of people in need in northern Syria; and
• Reopen the Bab al-Salam and al-Yarubiya border crossings in northern and northeast Syria, respectively.

To International Donors and their Implementing Partners:

• Commit to funding health care in northern Syria, including direct funding support to local actors in providing health care, and to government-held areas where aid is not being adequately distributed;
• Apply the right to the health standards when delivering aid to ensure it is available, accessible, acceptable, and of requisite quality;
• Monitor aid delivery to prevent inequitable and discriminatory distribution of health services; and
• Condition international aid on the Syrian government’s demonstrated ability to provide assistance to areas that it currently controls.

Introduction

The violence in Syria is not over. In the decade since it began, it has engendered an extensive humanitarian crisis. Syria is the location of a protracted, low-intensity conflict that continues in areas outside of government control, punctuated by periodic airstrikes by the Syrian government and its ally Russia. Nearly half of Syria’s population remains displaced – including 6.7 million people internally displaced throughout the country and more than 6.6 million refugees and asylum seekers who have fled Syria.[9]

An estimated 13.4 million people across Syria need humanitarian assistance – needs which increased more than 20 percent in 2020 due to the combined impacts of the novel coronavirus (COVID-19) pandemic and severe economic decline across Syria.[10] As Syria has struggled to address the catastrophic spread of COVID-19 throughout the country, populations in the opposition-held territories in the northwest, the Turkish-controlled areas in the north, and the Autonomous Administration of North and East Syria in the northeast have experienced the lack of a unified health sector, attacks against health facilities,[11] and barriers to accessing humanitarian assistance.

Population health needs far exceed the available facilities and personnel in northern Syria. The WHO recommends one hospital per 250,000 people;[12] however, the most recent Health Resources and Services Availability Monitoring System (HeRAMS) report from the Turkish Health Cluster covering April to June 2021 indicates that in northeast Syria, there were no functioning hospitals in two areas: Raqqa, which has an estimated population of 707,496, and Deir Ezzor, which has a population of 765,352.[13] Health care is instead provided at primary health centers and mobile clinics.[14] In al-Hasakah, there is one functioning hospital for a population of 1,127,309, roughly 20 percent of the WHO recommendation.[15] In northwest Syria and the Turkish-controlled areas, the number of health care workers – including doctors, nurses, and midwives – per 10,000 people falls far below the WHO recommended number of 22, with an average of nine health care workers across both areas.[16]

The COVID-19 pandemic highlights the depth of the disparities in Syrian health care. As of March 2021, the Syrian Ministry of Health reported having 6,326 beds to treat COVID-19 cases in isolation and quarantine centers in government-controlled areas.[17] In comparison, there were only 1,160 hospital beds and 1,088 beds in community-based treatment centers for handling COVID-19 cases in northwest Syria and Turkish-controlled northern Aleppo, respectively. In northeast Syria, as of February 2021, there were only 718 operational beds in COVID-19 facilities.[18]

Northern health care systems depend on a large and continuous flow of humanitarian aid to maintain services, including medications, supplies, human resources, and vaccines. Closing off this supply would debilitate these facilities and the organizations that support them. The Syrian government, in an apparent effort to control access to health care, has repeatedly attempted to impede the delivery of humanitarian aid to opposition-held areas.[19] In 2014, this led to the UN Security Council authorizing the use of cross-border aid delivery from Iraq, Jordan, and Türkiye through four international border crossings to supply opposition-held areas, including northern Syria. Currently, only the northeast border crossing of Bab al-Hawa remains open; the failure of the Security Council to keep it open would debilitate the northern health care systems’ facilities and the organizations that support them.

Political Actors and Territorial Control

The following table provides a general overview of factors influencing the health system in each of the three regions of northern Syria outside the control of the Syrian government.

Table 1: General Overview of Factors Influencing Northern Syrian Health Systems

	NORTHWEST SYRIA	TURKISH-CONTROLLED AREAS	NORTHEAST SYRIA
Geography [20]	Comprises the northern half of Idlib governorate, parts of western Aleppo governorate, and sections of northern Latakia and Hama governorates.	Two noncontiguous areas along Syria’s border with Türkiye that include most of northern Aleppo and parts of northern Raqqa and al-Hasakah governorates.	Comprises most of Raqqa and al-Hasakah governorates and the territory of Deir Ezzor governorate east of the Euphrates River.
Major cities	Idlib, Jisr al-Shughur, al-Atareb, and Harim	Afrin, A’zaz, Ras al-Ayn, Tal Abyad, Jarablus, Mare’, and al-Rai	Raqqa, al-Hasakah, al-Tabqah, and Manbij
Population	2.6 million[21]	1.4 million[22]	2.4 million[23]
Political entities with territorial control[24]	The Salvation Government (SG) and local councils	The Turkish government and the Syrian Interim Government (SIG)	The Autonomous Administration of North and East Syria (AANES)
Armed actors	Hayat Tahrir al-Sham (affiliated with the SG), Turkish-backed opposition groups, and several smaller jihadist groups.	Turkish military and the Turkish-backed Syrian National Army (often referred to as the Free Syrian Army), which is affiliated with the SIG.	Syrian Democratic Forces, which is affiliated with the AANES, and the Syrian military
Control of the health system	The SG Ministry of Health controls Idlib Medical School and health facilities within Idlib city and other areas under its control. The Idlib Health Directorate operates independently of any government and oversees hospitals across opposition-controlled Idlib.	The Turkish government directly oversees health care in towns and cities through health directorates, with support from the SIG Ministry of Health in rural areas.	The AANES Ministry of Health oversees the health sector in northeast Syria through the use of health committees in each region.
Access to humanitarian aid	Northwest Syria receives nearly all its humanitarian aid through the UN-authorized Bab al-Hawa border crossing with Türkiye. The authorization will be reviewed by the UN Security Council (UNSC) for extension on January 10, 2022.[25]	The Turkish-controlled areas lost direct access to UN humanitarian aid after the Bab al-Salam border crossing with Türkiye was not reauthorized by UNSC Resolution 2553 in July 2020.[26] They receive some humanitarian aid from Türkiye and northwest Syria.	Northeast Syria lost direct access to UN humanitarian aid after the al-Yarubiya border crossing with Iraq was not reauthorized by UNSC Resolution 2504 in January 2020.[27] It is now dependent on the Syrian government for access to UN aid.

Prior to the conflict, northwest and northeast Syria were among the least well-resourced areas in the country in terms of health care facilities. Over the last decade, the Syrian government’s control over the north has periodically shifted, leading to an eventual withdrawal of the Syrian Ministry of Health from non-government-controlled areas.[28] What follows is a description of the local health authorities in each area which have worked with local community councils, as well as donors and the NGOs they fund, to provide health services.

Northeast Syria

In northeast Syria, the Autonomous Administration Health Commission oversees the health system through “health committees” that operate across the region. In Deir Ezzor governorate, however, the Autonomous Administration exerts minimal influence on the health system, which is mostly overseen by a coalition of NGO workers and UN representatives known as the Health Working Group, overseen by the International Relief-led Northeast Syria Forum.

Since July 2020, only one border crossing between Türkiye and Idlib, Bab al-Hawa in northwest Syria, remains open, leaving the northeast without direct access to United Nations coordinated aid.^[29] This has led to further disparities in humanitarian aid distribution throughout areas in northeast Syria outside of Syrian government control and has led to shortfalls in fulfilling the key determinants of health, let alone medical care that fulfils the right to health framework.^[30]

Northwest Syria

In Idlib governorate in northwest Syria, the Idlib Health Directorate (IHD) has provided oversight of the health sector. Originally an independent network of health workers, the IHD developed into a de facto health ministry with links to the Syrian Interim Government and local health councils across Idlib.[31] A group of NGOs operating in northwest Syria committed to working within this local governance framework in September 2015 to promote donor collaboration and facilitate coordination of health policy;[32] many still operate in the region. The Hayat Tahrir al-Sham-backed Salvation Government became the dominant governing body of opposition-held northwest Syria in January 2019 (see Annex 1). The Salvation Government Ministry of Health overlaps territorially with the IHD but reportedly has little capacity or experience in managing a health system. This lack of capacity and experience, along with the lack of coordination with the IHD, has reportedly disrupted the health sector in this area.[33]

Turkish-Controlled Areas

In Turkish-controlled areas, Türkiye’s Ministry of Health supports major hospitals in cities such as Afrin, A’zaz, and Jarablus, while the Syrian Interim Government Ministry of Health supports health care in rural areas.[34] Türkiye has made significant investments in the health care system in the areas it controls. It has also imposed a piecemeal system of regulations that have hindered relief efforts, including by preventing Syrian and international humanitarian organizations from operating in Turkish-controlled areas without working through Turkish-approved organizations.[35] While regulation of the health sector is important for ensuring quality, Türkiye has used it to crack down on humanitarian organizations operating in northeast Syria in an apparent effort to limit the amount of aid reaching areas controlled by its perceived opponents, the Syrian Democratic Forces.[36]

Methodology

The findings in this report are based on 20 semi-structured interviews conducted by Physicians for Human Rights (PHR) researchers between August and October 2021 with stakeholders who have experience working in health systems in northwest and northeast Syria, including Turkish-controlled areas. In northwest Syria, respondents included health workers and health facility or hospital administrators, health system researchers, NGO staff, and donors. In northeast Syria, respondents included researchers, a health care provider, NGO staff, and UN representatives. In Turkish-controlled areas, respondents included health care administrators and a doctor. All respondents were selected for their knowledge of the current health care situation in each geographical area and for their firsthand experience responding to the COVID-19 pandemic in Syria.

Interviews were carried out using a semi-structured interview guide, which was developed in English and translated into Arabic by a native Arabic speaker and PHR staff member. Researchers with native Arabic and English skills conducted interviews remotely via Zoom. Most interviews were conducted in Arabic, with a small number conducted in English with international respondents. Following each interview, the interviewers conducted a debriefing to develop a codebook. The codebook reflected themes related to the health system, the right to health, humanitarian access, vulnerable populations, armed groups, relevant actors, COVID-19, non-medical challenges, recommendations made by respondents, and dynamics between actors. Primary data was then transcribed into Arabic and analyzed by Arabic-speaking members of the PHR team using qualitative coding software.[37] Findings were organized by key themes, which were assessed and formulated into legal and policy recommendations at the end of the report.

Researchers also conducted a desk review of academic and gray literature, using search engines including Google Scholar, WorldCat, and PubMed, with key words in English in combination with relevant geographic terms, including: human resources, health system governance, health information systems, medical supplies, technology, finance, governance, health infrastructure, and various types of health conditions (non-communicable diseases, mental health, nutrition, reproductive health, infectious disease outbreaks). The literature reviewed included open-source articles, UN agency reports, NGO reports, think tank white papers, and reports by media outlets on the health systems in northern Syria.

This report has several key limitations. It includes few perspectives from women in the health sector (n=2). Female staff inside Syria were hesitant to speak to the PHR research team for security and personal reasons. Other limitations include reliance on primarily English language resources for the desk review, as documents written in other languages, such as Arabic, Russian, and Turkish, were not included; the lack of recently published data about Syria’s population, public health issues, or health systems operating within Syria; and the challenge of documenting the needs of medical facilities in areas outside of Syrian government control due to ongoing fears of personnel working in these facilities facing retaliation from local actors for discussing mismanagement of resources, corruption, and other sensitive topics.

“The first challenge is the continuous bombing and targeting of health facilities by the Syrian and Russian regime. This constant fear and terror, we do not know at what moment the facility, including its employees and equipment, can disappear.” [38]

Female administrator, Gaziantep

Findings

Ongoing Physical Insecurity: Attacks on Health Care Facilities and Workers

As has been well-documented, violence against health care workers by the Syrian government, its allies, and other armed actors has impaired the health sector’s ability to function. A doctor from northeast Syria reported that in the first half of the conflict, health care workers in Syria established temporary field hospitals in businesses and private homes to avoid repeated aerial attacks on formal health facilities.^[39] Attacks continue to preoccupy health care workers and take a psychological toll. A general surgeon from Deir Ezzor expressed concern that any large, well-staffed hospital with supplies and equipment can expect “to be targeted at any moment” and attacked.^[40] 

The current health crisis in Idlib’s Jabal al-Zawiya region demonstrates the effects of the periodic attacks. Türkiye and Russia negotiated a 2018 ceasefire that allowed northwest Syria a period of relative stability, and the health system in most of Idlib improved. However, in Jabal al-Zawiya, health care services rapidly deteriorated because opposition forces there continued to operate.^[41] Before the ceasefire, there were several hospitals in Jabal al-Zawiya district. Due to security concerns, many health workers fled to safer regions, and NGOs stopped supporting health facilities in the area.^[42] By 2019, only one medical point remained, the Mara’ayan Medical Center.^[43] On September 8, 2021, this last facility was destroyed by an unknown actor operating from an area jointly controlled by the Syrian government and the Syrian Democratic Forces,[44] leaving Jabal al-Zawiya district without a health facility.^[45] An administrator of a hospital in a nearby town cited the uptick of patients to his facility after this attack: “Two weeks ago, there was an attack on Jabal al-Zawiya right next to the hospital [effectively destroying it]. In the southwest part of Idlib, there are not many hospitals. If an attack happens far away, patients come here.”[46] 

“With regard to cross-border aid, it is the window through which we breathe, and it must not be closed…. The health sector is walking on a crutch, and [if] this crutch is broken, it will bring down the sector.”[47] 

NGO administrator, Idlib

Cross-Line vs. Cross-Border Aid

Humanitarian access is essential to meet the most basic needs of the health systems serving the more than 6.8 million people in need of humanitarian assistance in all areas of northern Syria, including areas held by the Syrian government.[48] The dynamic security situation and fluctuating donor priorities threaten humanitarian actors’ ability to provide lifesaving care and sustainable support. Some respondents indicated that the situation was not much better in government-controlled areas.[49]

International humanitarian law guarantees civilians the right to lifesaving assistance in areas affected by conflict.[50] The two main ways of delivering humanitarian aid to affected populations in Syria are through “cross-line” and “cross border” operations. “Cross-line” delivery occurs within Syria, from government-held to non-government-held areas. It usually involves overland convoys, although in a few cases shipments have been made by air.[51] “Cross-border” aid is delivered by convoys from other countries directly into non-government-held areas. Cross-border aid into Syria now comes exclusively from Türkiye, although in the past it also came from Iraq and Jordan.

On July 14, 2014, United Nations (UN) Security Council Resolution 2165 authorized UN humanitarian agencies and their partners to provide humanitarian assistance to Syria through four international border crossings, “to ensure that humanitarian assistance, including medical and surgical supplies, reaches people in need throughout Syria through the most direct routes” (emphasis added). [52] Resolution 2165 established two such border crossings at Bab al-Salam and Bab al-Hawa along the Syrian-Turkish border, a third at al-Yarubiya on the Syrian-Iraqi border, and a fourth, al-Ramtha, on the Syrian-Jordanian border.[53]

Aid organizations channeled significant humanitarian aid to millions of people using these four border crossings. In recent years, Russia – an ally of the Syrian government – and China have used their veto or threats of vetoes in the Security Council to trigger the incremental closure of the border crossings. The lifeline for humanitarian assistance in Syria has therefore been reduced to one border crossing, which the UN Security Council has repeatedly reauthorized for six months at a time.[54] This has placed significant pressure as well as instability for planning on the Bab al-Hawa border crossing, which supplies aid to the entire northern Syria region, including northeast Syria, where humanitarian needs continue to increase. While non-government-controlled areas can, in theory, receive humanitarian aid coordinated through Damascus, PHR’s 2020 report about the obstruction and denial of humanitarian access in opposition-held areas retaken by the Syrian government in the south demonstrated the failings of that system.[55]

A doctor in northeast Syria estimated that doctors working in a public hospital see “40-50 patients in two hours” and that “usually 150-200 patients are waiting.”

A Snapshot of Northern Syria Health Care Systems

Although each region discussed in this report is different, they share common problems related to availability of and access to health care facilities. PHR’s interviews with administrators, health care workers, and researchers describe health systems crises in northern Syria, in which health care availability and access differed significantly. Across all areas, respondents indicated that, overall, the number of health facilities and staffing was insufficient for the population.[56] Even in Idlib, which was relatively well-served, only 600 doctors served a population of approximately four million in 2019, 15 percent of the World Health Organization’s (WHO) recommendation for physician staffing.[57] High patient loads have created significant stress for health care workers and have further pushed health care workers to leave Syria. A doctor in northeast Syria estimated that doctors working in a public hospital see “40-50 patients in two hours” and that “usually 150-200 patients are waiting.”^[58]

Funding, Location, and Transportation

Each region’s health ministry oversees its own system; respondents indicated that the majority of funding and supplies comes from international aid. Public, private, and NGO-run health facilities exist in a loose framework without strong coordination mechanisms. Individual hospitals and clinics have been forced to compete for funding and supplies in the absence of these mechanisms. Health administrators, health care providers, and researchers all reported significant differences in the amount and level of health care available among the regions, as well as within a given region and in particular communities. For example, northeastern communities in Deir Ezzor and Raqqa governorates have less access to health care services than those in al-Hasakah. Donors are hesitant to invest in these areas, given access constraints due to ongoing security dynamics.

Health facilities in all three areas are concentrated in urban areas, leaving rural and other populations with little to no access to health care. Respondents reported that, as a result of security factors and donor prerogatives across all three territories, health facilities were created in geographical “clusters,” resulting in a relative abundance of health care in some areas and none in others. Additionally, vulnerable populations, including women and physically disabled people, were among those most severely impacted, as discussed further below.

Travel is expensive and dangerous across northern Syria. Patients in underserved areas are forced to travel long distances, ranging from six to more than 370 miles, depending on the type of care required.[59] Transportation costs are a serious barrier to most families, especially if multiple trips are required.[60] In al-Atareb, in northern Aleppo, the estimated cost in June 2021 for a one-way trip to the nearest surgical hospital was $25, an amount 17 times the average daily income.[61] Patients face additional security risks when traveling through checkpoints manned by armed groups between areas for medical care.[62]

“Most hospitals do not have ambulances. Most health centers do not have doctors.”[63]

Administrator in a health facility in Deir Ezzor

Northeast Syria

Since 2019, the Syrian Democratic Forces, the military that supports the government of northeast Syria, has worked with the Syrian military to repel the Turkish military’s incursion into northern Syria. In Deir Ezzor governorate, the Syrian government controls the area to the west of the Euphrates, and the Syrian Ministry of Health provides some funding and aid for that part of northeast Syria’s health system, although it reportedly does not meet local needs.[64] In the northeast, the Autonomous Administration Health Commission oversees the health system through “health committees” that operate across the region. The health system in Raqqa depends heavily on international humanitarian aid, which is administered through local NGOs that rely on funding from the United States to provide services. This funding was halted in March 2018, and although it has since resumed under the Biden administration, U.S. officials project that the effects of the funding freeze will continue through 2022.[65] To the east of the Euphrates in Deir Ezzor, the Autonomous Administration exerts minimal influence on the health system. The Health Working Group, which oversees the health system to the east of the Euphrates, is modeled on the WHO-led Health Cluster operation based in Gaziantep, but respondents indicated that it lacks the resources to serve as a coordination mechanism.[66] In addition, the political struggles between the Autonomous Administration of North and East Syria and the Syrian government have created a difficult environment for humanitarian organizations.[67] 

The UN estimates there are 1.9 million people in need of humanitarian aid in northeastern Syria alone.[68] The closure of the al-Yarubiya border crossing in January 2020 forced its population to rely on cross-line aid from adjacent regions within Syria, specifically Turkish-controlled areas and areas under Syrian government control. This reportedly resulted in severe shortages of medical supplies, including “medications to treat diabetes, cardiovascular and bacterial infections, as well as post-rape treatment and reproductive health kits.”[69] The problems that resulted from suspending cross-border aid to northeast Syria exemplify the impact on the right to health and humanitarian assistance if humanitarian supplies are not delivered efficiently. For example, soon after the al-Yarubiya border closure in January 2020, there was reportedly a significant coordination problem with delivery of assistance from inside Syria, including the routing of 85 metric tons of medical supplies to Damascus and a nine-month delay before they were sent to northeast Syria, by which time many of the medications had expired.[70] Land-based cross-line operations are fraught with danger, even when the government has granted permission for them to take place.[71] This allowed the Syrian government to ship aid by air to Qamishli, where the Autonomous Administration is based; reportedly, this aid reached only the health facilities in government-controlled areas within northeast Syria.[72] In 2020, only 31 percent of medical facilities in northeast Syria benefited from cross-line humanitarian assistance from Damascus.[73]

Northeast Syria has therefore become almost completely dependent on aid that is transported by land from the Bab al-Hawa crossing in the northwest through Idlib and the Turkish-controlled areas, a journey of at least 275 miles. A hospital administrator in Deir Ezzor reported that small quantities of medications are delivered every three to four months and are often limited to painkillers and antibiotics.[74] Health facilities must factor in the cost of transportation and the payment of bribes to different actors, which can easily triple the price of medications.[75]  

Although overall northeast Syria is the least resourced of the three areas, there are multiple health facilities in the governorates of Raqqa and al-Hasakah in the northern part of the region. In 2020, there were reportedly three partially functioning public hospitals in Deir Ezzor governorate on the western bank of the Euphrates River, in territory controlled by the Syrian government. In contrast, the area of Deir Ezzor governorate to the east of the Euphrates River, controlled by the Autonomous Administration – which had an estimated population of 300,000 in 2018 – has had only one large public hospital supported by an NGO, in the town of al-Shaheel.[76] These disparities can be traced back to former ISIS control of these areas,[77] when, according to a doctor practicing in Deir Ezzor,[78] “most doctors in Raqqa and Deir Ezzor fled to Türkiye and [Syrian government-controlled] areas.”[79] He said that many health workers have not returned.

Some health care workers attribute the Kurdish-led Autonomous Administration’s perceived lack of engagement with the health system in Deir Ezzor to discrimination against the Arab population living there.  The doctor practicing in Deir Ezzor noted that the lack of NGO activity could be due to the dominance of tribal factions[80] and an absence of stability or civilian institutions in the greater Deir Ezzor area:

“Al-Hasakah and al-Qamishli have security, safety and electricity, and courts. In our areas, there are no courts, no police…. Organizations like to go to a secure area in which there is a judiciary, police, and courts. Our areas are governed by tribalism.”[81]

Most training opportunities for health care workers are concentrated in the areas where the Autonomous Administration has direct oversight and where NGOs can operate in more secure conditions, including al-Hasakah and al-Qamishli. This poses challenges for Arab health care workers from under-resourced areas, such as Deir Ezzor and Raqqa, who want to access these trainings. At the same time, ethnically Arab health care providers expressed hesitancy about working in Autonomous Administration-managed facilities. One doctor explained,

“If things changed on the ground, and we ended up needing to go to Free [Syrian] Army[82]-controlled areas or to Türkiye, we might be arrested for having worked with the Syrian Democratic Forces (the military arm of the Autonomous Administration).”[83]

Remote areas along northeast Syria’s border with Iraq are especially underserved, as there are few doctors and the nearest health facilities are hours away along unpaved roads through rugged terrain.[84] For some patients, a trip to a health facility can be a multi-day journey with no guarantee that the treatment they need will be available when they arrive.[85]

Northwest Syria

Two competing opposition entities in Idlib claim control over overlapping areas in which health care is provided (see Table 1). A cardiologist in Idlib described how the competition between the Idlib Health Directorate and the Salvation Government Ministry of Health has resulted in a vacuum of health policy. Subsequently, the funding choices made by donors and international organizations play a significant role in determining local health priorities.[86] A health care professional in A’zaz, in the Turkish-controlled areas, noted that donors prefer to invest in projects in Idlib because it has “a larger population [than northeast Syria or the Turkish-controlled areas], which means that more projects are implemented there, and because organizations have greater presence and weight there.”[87]  

The UN estimates that 3.4 million people require humanitarian aid in northwest Syria; as of June 2021, UN aid through the Bab al-Hawa crossing reaches 2.4 million Syrians each month, leaving one million without adequate assistance.[88] In August 2021, a single cross-line shipment of aid was delivered to northwest Syria.[89] Residents of northwest Syria and humanitarian actors protested, fearing it might be an attempt by the Syrian government to demonstrate that cross-line operations can replace the much larger cross-border mechanism.[90] The Idlib health care provider cautioned, “Stopping [aid through] the Bab al-Hawa crossing is a sentence for the region to fall.”[91] The UN Secretary-General noted that cross-line aid, “even if deployed regularly, could not replicate the size and scope of the cross-border operation.”[92] Health care workers in Idlib distrust and fear aid delivered through Damascus. A health care administrator in Idlib noted,

“There is complete lack of trust in the Syrian authorities working from Damascus to secure health care services in areas outside of its control. On the contrary, we think a regime that bombards hospitals cannot be trusted to send medications and treat people.”[93]

Even in comparatively well-resourced northwest Syria, many areas lack access to health care. A cardiologist in northwest Syria explained that most people in underserved areas who need medical care must borrow or rent a car, endeavors that have continuously increased in price due to rising costs of fuel and the impact of the conflict on the local economy.[94] Patients living near large hospitals might be able to request an ambulance or receive transportation assistance from organizations like the White Helmets, first responders who provide ambulance services,[95] but remote, mountainous areas like Jabal al-Zawiya, Jisr al-Shughur, Darkush, and Salqin are far from northwest Syria’s large hospitals,[96] which are located along the border with Türkiye, away from active areas of fighting.[97]As a result, patients in those areas are forced to travel at great costs through dangerous routes to access care.

Because humanitarian aid fails to meet population needs, some humanitarian aid flows into northern Syria by informal smuggling at crossings with Türkiye and Iraq. A health care provider explained that he and his friends resorted to smuggling surgical equipment across the border.[98] He also reported that bribes must be paid, adding to the cost of delivering supplies.

“Local councils manage themselves independently. Turkish hospitals manage themselves independently…. Today, there is not any real planning here or in northwestern Syria, in Idlib.”

Health care provider, A’zaz

Turkish-Controlled Areas

In Turkish-controlled areas, the health system is overseen by the Turkish Ministry of Health, with the Turkish-backed Syrian Interim Government addressing needs in rural areas.[99] Health care has gradually improved in some of the areas in which Türkiye took control through its military campaigns from 2016 to 2019; others, such as Ras al-Ayn and Tal Abyad, remain in great need. Some Syrian health workers have criticized Türkiye for tightly regulating the health sector without providing meaningful planning or coordination support.[100] A health care provider in A’zaz confirmed that the lack of coordination between Turkish health authorities, NGOs, and the private sector has led to an abundance of services in some places, while other areas remain unserved.[101] An administrator in a health facility in A’zaz described this phenomenon, noting, “A’zaz has two women’s hospitals, about 200 meters apart. In another area there are villages with no medical service.” He further explained the political reality behind this inequality:

“We have become mini states in the north. The statelet of A’zaz is not the statelet of Mare’, or the statelets of Jarablus and al-Bab. Each one is a little state acting on its own, with a local council acting on its own. Frankly, [Türkiye’s] policies have encouraged this division and support it.”[102]

In areas where services are available, they do not always reflect community needs. For example, the health care provider in A’zaz observed that the number of primary health care centers exceeds the current need, but the quality of health care they provide is very basic.[103] It has become practically impossible for patients with chronic illness or significant injuries to cross into Türkiye for secondary or tertiary care.[104] 

Populations Most Adversely Affected by Health Disparities

While the entire population of northern Syria reportedly suffers from lack of availability and access to adequate health care, multiple respondents mentioned the disproportionate impact of poor health care governance on women and people with physical disabilities.

Health Care for Women and Girls

Northeast Syria

In the northeast, women’s health is limited mainly to routine reproductive health visits and family planning. Specialized medical services for women with ovarian cysts are not supported because organizations consider it a non-primary condition. Similarly, few health care workers in the region have the experience and equipment to diagnose and provide appropriate medical prevention and care for breast cancer. A midwife in Raqqa noted the rise in breast cancer rates and the attendant need for mammograms, stating, “Al-Tabqah, Raqqa, and Manbij do not have any [machines for performing] mammograms. We rarely find a specialist who has experience detecting it.”^[105]

In addition to the lack of gender-specific health services, women and girls face formal and informal barriers to accessing health care, including access to female providers.[106] Female patients may prefer – or are culturally expected to be seen by – female providers, yet female providers are rare. Women across Syria are often accompanied for protection by their husbands or male relatives when they travel to access health services.[107] Even female health care workers may be stopped at checkpoints and prevented from reaching patients if they are not accompanied by a male family member.^[108] Adult men may avoid crossing checkpoints to avoid detention, which would pose potential travel constraints for women and children seeking care across territorial lines. Women and girls displaced from urban to rural areas are particularly affected, since they are often in unfamiliar settings without the male family members needed to accompany them to access care.^[109]

Northwest Syria

A sexual reproductive health technical advisor in Gaziantep who oversees health programming in northwest Syria explained that when health services began to shift to field hospitals in response to aerial assaults by the Syrian government, health facilities functionally stopped providing reproductive health care.^[110] The gap widened as the destruction of health facilities and loss of health workers reduced and eliminated services. As health systems were slowly repaired in areas benefiting from ceasefire agreements, she noted that reproductive health care was not prioritized and lagged behind other services.^[111] She explained that attempts by NGOs to finance and support health services for women, including reproductive health care, have been met with systemic obstacles. For example, when health care organizations have provided training on health services for women, health workers have shown little interest and lackluster engagement. The same technical advisor indicated that some Syrian health officials have dismissed women’s health care and protection issues as unimportant compared to conflict-related health care or drug addiction.^[112]

The sexual reproductive health advisor also noted that implementation has sometimes suffered from the absence of female health experts in decision-making positions in organizations that had invested in providing women’s and reproductive health care.^[113] She stated, “When I meet with organizations, [the staff] are all males. There is no female in an important position to talk about the reality of the women and girls to whom I provide humanitarian aid.” Even when providing essential feminine hygiene products, such as sanitary napkins, she reported that lack of knowledge led to issues with the quality of supplies.^[114]

The absence of qualified medical personnel has shaped access to health care for women and girls. Without skilled obstetricians and midwives, the rate of natural births has dropped as pregnant women, seeking to control the time of delivery, have opted for cesarean sections. A female NGO administrator working on women’s health issues in northwest Syria estimated that 40 percent of births in Idlib are now cesarean sections, compared to only 19 percent across Syria in 2011.^[115] A midwife working in Raqqa reported a similar phenomenon in northeastern Syria.[116]

57 percent of households in northwest Syria and 55 percent of households in northeast Syria have at least one person with a disability. As many as 30,000 new cases are added each month to the number of people with disabilities in Syria.

Access Issues for People with Physical Disabilities

The UN Humanitarian Needs Assessment Programme (HNAP), a joint UN assessment for determining population needs in Syria, estimated in 2020 that 13 percent of the entire Syrian population has a disability affecting mobility.[117] Significantly, HNAP estimates that 57 percent of households in northwest Syria have at least one person with a disability, and 55 percent of households in northeast Syria have at least one person with a disability.^[118] Researchers estimate that as many as 30,000 new cases are added each month to the number of people with disabilities in Syria, caused by a combination of war injuries due to explosions and other violence, and disabilities caused by sequelae of untreated illness such as strokes and diabetes.[119]

The disabled population includes 14 percent of people in Idlib, 15 percent in al-Hasakah, 16 percent in Aleppo, 18 percent in Deir Ezzor, and 25 percent in Raqqa.^[120] Respondents indicated that the use of repurposed buildings as primary-care health points has limited access to health care for people with physical disabilities. A surgeon working as a director for an organization based in Gaziantep, Türkiye covering northwest Syria explained that in facilities with multiple floors, the lack of elevators and other accessibility features creates additional hurdles for patients with physical disabilities.^[121]

Specialized services for people with disabilities are reportedly rare. For example, the midwife in Raqqa explained that for the many people who have lost limbs due to mines and other conflict-related injuries, prosthetics are unavailable.^[122] She reported that wheelchairs and crutches were in short supply, and cost poses a substantial barrier. She noted, “An electric wheelchair costs $5,000, a regular wheelchair is $150, and a crutch is $25. If the wheelchair breaks, it will not be replaced.”[123] Even the cheapest options are unaffordable to local populations struggling with poverty: the average laborer in northwest Syria made 69 cents a day in January 2020.[124] The same midwife expressed concern that conflict-related injuries, such as hearing loss due to explosions, have increased and that the limited treatment services available are prohibitively expensive.”^[125]

Locally Led Approaches in the Coordination of Humanitarian Aid

Local NGOs have spearheaded the humanitarian health response in northern Syria, supported by international NGOs and their respective donors. The UN Office for Coordination of Humanitarian Affairs indicates that 25 local health sector organizations operate in northwest Syria and 37 in northeast Syria.[126] The WHO-led Health Cluster coordinates the humanitarian health response in northwest Syria by meeting regularly with health organization representatives based in Gaziantep, across the border in Türkiye. In northeast Syria, the Northeast Syria Forum oversees all health sector responses.[127]However, in both areas, community-led approaches are lacking to identify critical health needs and provide insights on challenges and solutions for these communities.

A Syrian health researcher respondent highlighted the significance of ground-up approaches to humanitarian programming in northeast Syria:

“In northeast Syria, there should be more links between the different levels – the main level of the health department of the Autonomous Administration should have more links with other governorate levels as well as the sub-district level. More work should be done to decentralize health policies; for example, each governorate – Raqqa, al-Hasakah, and Deir Ezzor – should develop its own local health policies and the health department in the Autonomous Administration should coordinate to harmonize these approaches.” [128]

He also observed that models for coordination, like the Health Cluster cross-border operation led by WHO from Gaziantep, are effective but require support to be sustainable:

“In northwest Syria, there have been some innovative practices that need to be supported to ensure sustainability…. Projects that use this bottom-up approach increase the link between international and local actors. For example, they have clusters in Gaziantep that include local actors and encourage them to participate in decision-making. This needs to be maintained and supported.”[129]

Turkish authorities have permitted local NGOs in Turkish-controlled areas to establish primary health care centers. However, the researcher noted that “In northern Aleppo [administered by Türkiye], there should be some local Syrian lead. The Turkish Minister of Health should work with a local health authority – for example, the Aleppo Health Directorate or even the [Syrian] Interim [Government] Ministry of Health or any Syrian lead entity – to plan for the health system in this region.”[130]

COVID-19 Response in Northern Syria

In addition to the struggles with availability and access outlined above, the COVID-19 pandemic has put additional strain on the already weak health systems in northern Syria. The rollout of COVID-19 programming – including the creation of isolation and treatment facilities, new health guidelines, and vaccine campaigns – has been impeded by pre-existing disparities in health care capacity, limited patient access, and lack of trust in institutions. These problems are overlaid on the existing gaps in each system.

In 2020, global public health workers feared the COVID-19 pandemic could sweep through the dense and economically vulnerable populations in northern Syria. To prepare, there was a push by donors and NGOs in northern Syria to establish COVID-19 isolation centers and hospitals and to train health care workers. However, in each region, many Syrians chose to avoid seeking treatment for COVID-19 for a mix of economic and cultural reasons. International actors, including the COVID-19 Vaccines Global Access (COVAX) initiative, have worked to ensure access to COVID-19 vaccines in northern Syria, largely through the Bab al-Hawa border crossing. However, the same issues with availability, access, and hesitancy apply. Vaccine hesitancy in the populations of northern Syria is reportedly widespread, often stemming from mistrust in institutions and the spread of rumors and misinformation regarding COVID-19 vaccines.[131]

The number of coronavirus cases in the northwest increased 170 percent in September 2021, filling the intensive care units as COVID-19-designated health facilities reached 100 percent capacity.

Funding: Shifting Priorities for Donors and Providers

Concern over the spread of COVID-19 in non-government-controlled areas led to donors restructuring their health programming priorities in northern Syria. Though this resulted in a surge in funding for COVID-19 prevention and management projects, the resource reallocation came at the expense of other health services. An administrator in Idlib described how the pandemic “forced some health centers to turn into COVID-19 centers, and people had more difficulty accessing health centers.”^[132] He further explained that the pandemic greatly affected the decisions of the donor organizations “that carry the health sector” because much of their support was shifted towards establishing community isolation centers. [133] The distribution of these COVID-19 activities appears to have been uneven, however. Health care staff covering both northwest Syria and Turkish-controlled areas expressed concern about the availability of COVID-19 services.

International funding from donors for many COVID-19 projects is set to expire, despite the fact that Idlib is now experiencing its largest wave of COVID-19 cases yet.[134] The number of coronavirus cases in the northwest increased 170 percent in September 2021, filling the intensive care units as COVID-19-designated health facilities reached 100 percent capacity.[135] Health care workers in facilities in northwest Syria are increasingly forced to make difficult choices about who can get care.[136] A surgeon from Idlib reported that oxygen shortages in his hospital have forced them to stop all elective surgeries to conserve oxygen for emergency surgeries and the newborn intensive care unit.[137] A respondent from Idlib reported his belief that the priority should be “to finance COVID-19 hospitals, even if support for isolation centers stops. If you choose between the two, hospitals are more important. It is lack of funding that will determine the health sector’s ability to respond to the potential peak.”[138] Another respondent from Idlib stated, “If the disease spreads again, we do not have enough hospitals and sufficient centers. There are some community isolation centers and corona hospitals … but [the health system] certainly will not survive a pandemic.”[139] The surgeon from Idlib explained, “We have 10 rapid tests in our hospitals. That’s it. We sent the patients to the isolation center – which ran out of rapid tests,” adding that currently health care providers diagnose based only on symptoms.[140]

Widespread poverty has had an enormous impact on people’s ability to follow COVID-19 guidelines. Across the country, nine in 10 Syrians live below the poverty line. The majority of the population relies on humanitarian aid.

Poverty’s Role in Determining Adherence to COVID-19 Protocols

Widespread poverty has had an enormous impact on people’s ability to follow COVID-19 guidelines. Across the country, nine in 10 Syrians live below the poverty line.[141] The majority of the population relies on humanitarian aid. Although it is difficult to track current wages, in December 2020, northwest Syria reported the lowest wage rate in the country (SYP 3,325 or $1.32 a day), followed by northeast Syria (SYP 4,343 or $1.73 a day).[142] Socially distancing from work while symptomatic would be difficult for those who could not afford to lose even a day’s work. An administrator in a health facility in Idlib explained that resistance to prevention practices is based partly on poverty, noting, “If the day laborer works, he eats. If he does not work, neither he nor his family eats.”^[143] An administrator in Idlib explained that some people who contract COVID-19 have concealed their condition to avoid social and financial repercussions.^[144]

An orthopedic surgeon expanded on this issue, noting the prohibitive expense of personal protective equipment (PPE) could lead to a public health disaster in northern Syria:

“Masks, gloves, and sterilizers are available in general. People did not go out to buy them due to the economic situation…. In Türkiye, in the first wave, they distributed masks to people, who took them for free at the pharmacy. In Syria, there are no possibilities and no preparation, if a major pandemic begins, there is nothing to stop it.”[145]

COVID-19 has added a layer of challenge due to global competition for supplies, placing a more significant strain on humanitarian workers to secure medical supplies by any means possible. In March 2020, Türkiye prohibited the export without pre-approval of many kinds of medical equipment and supplies, including PPE, ventilators, oxygen concentrators, and intensive care monitors.[146] The Turkish export ban forced NGOs in northwest Syria to procure the necessary supplies on the black market from inside Syria with difficulty and at great cost.[147]  

COVID-19 in Northeast Syria

Respondents indicated the COVID-19 response in northeast Syria has been weak and unsustainable. As discussed above, the northern areas, including al-Qamishli, benefit from many of the health resources, while Deir Ezzor has one functioning public hospital for the entire governorate, and few health facilities. An NGO mission director whose organization covers Raqqa and Deir Ezzor explained that humanitarian organizations have provided intermittent support to isolation and COVID-19 centers, but

“Once the [COVID] wave ends, so does the funding. In Deir Ezzor, at the start of the second wave, only one out of four COVID-19 and isolation centers was functioning. The other three had closed after their funding stream was suspended.”[148]

A general surgeon working in Deir Ezzor described how patients slept on their own bedding on the isolation center floor because there were more than three times as many critical patients as available beds:

“When COVID-19 hit, in Deir Ezzor, the COVID-19 center had 40 beds, but there were approximately 130 patients in critical need. People used to sleep on the floor. They would bring their mattress and cover from home. We are talking here about critical cases that require oxygen.”[149]

The lack of capacity reportedly impacted testing. An NGO program manager explained that, in the early phases of the pandemic, there were no COVID-19 labs in the northeast. Instead, health authorities would send PCR tests by air from al-Qamishli to Damascus.[150] Reportedly, there is now one laboratory in al-Qamishli and PCR tests are free, with the results provided in 48 hours. However, there are constant complaints about the lack of PCR kits. The same staff member reported that for three months the al-Qamishli lab had been “calling for more kits. This lab covers al-Qamishli, al-Hasakah, Raqqa, and Deir Ezzor. This lab’s response is very weak compared to the needs.”[151] As a result, the NGO mission director stated that “no one trusts the official reported cases of COVID because the lab itself does not have enough number of kits.”[152]

An NGO administrator explained that since Deir Ezzor is a very large governorate, his hospital had wanted to fund a project to establish its own PCR lab there. However, he noted that “the local authority refused and there was no room at all for discussion,” adding that “they considered it [a] political [matter].”[153]

The administrator noted that the lack of PCR tests and laboratories resulted in underreporting in regions without them, highlighting the disparities between areas in the northeast: 

“The [reported] numbers are wrong. For example, last month in al-Hasakah, there were 1,500 positive cases compared to 63 in Deir Ezzor. This is mainly because in al-Hasakah, the distance between where the swab is taken and the lab takes only a few minutes, but swabs in Deir Ezzor can take four to five days to arrive [at the lab] in Qamishli. Most arrive damaged.”[154]

In Raqqa, an NGO staff member reported that vaccines are freely available at fixed vaccination points for anyone who wants one; however, there are high rates of vaccine hesitancy.[155] A surgeon in Deir Ezzor explained:

“People in the northeast do not trust the regime. Since the vaccines provided by the World Health Organization were delivered to the Syrian government and then transferred to areas held by the Autonomous Administration, people didn’t accept [the vaccines] because they thought they had been tampered with.” [156]

He added that doctors and health care workers were among the largest percentage of those vaccinated, “because it was explained to us that the vaccines were coming from the WHO and that the regime had not interfered in the process.”[157] As of November 4, the WHO reported that 42,077 people in northeast Syria had received at least one dose of a COVID-19 vaccine, including 20,885 who had received a second dose.[158]

COVID-19 in Northwest Syria

In neighboring Idlib, ventilators have become more readily available than in other areas,[159] yet the need is greater than the supply. The surgeon in Idlib stated, “We see people die in front of our eyes for many reasons. Now, we see people dying from a lack of oxygen. Türkiye is next to us – why can’t we receive oxygen cylinders [from Türkiye]?”[160] According to the Syrian American Medical Society, the lack of oxygen stems from difficulties in the supply chain, including the logistical challenges of maintaining oxygen generators, procuring spare parts, and transporting oxygen cylinders over poorly maintained roads.[161]   

The global impact of COVID-19 also resulted in some international donors withdrawing from their commitments as their economies were impacted and they began focusing on their own COVID-19 responses. An administrator from Idlib reported that his organization has struggled to deal with the loss of a major donor from East Asia when it fully cut funding in 2020.[162]

In Idlib, health care staff were reportedly trained on COVID-19 protocols. An NGO administrator in Idlib stated, “Almost all the health sector has been trained on coronavirus procedures. My organization worked on capacity building in this field and included almost all health personnel. People are ready to deal with disease.”[163] Another respondent, a cardiologist, added that, at first, an orthopedist ran the COVID-19 program but that eventually internists were recruited.[164] 

An administrator in Idlib noted that cultural issues may prevent effective management of the virus:

“The biggest problem is what happens after entry into the community COVID-19 center. The measures were not encouraging for people. For example, when a patient enters the isolation center, he was not allowed [visitors]. When a death occurred, the method of burial and protocols are without social mixing…. [Because of this], people hesitated.”

He added that COVID-19 patients remain at home, going to the hospital only when the situation deteriorates.[165]

Women were reportedly among the least likely to use a community COVID-19 isolation center. An administrator at an NGO in Idlib explained that “The nature of the services and centers designated for corona do not pay much attention to privacy, especially for women, which makes them less likely to obtain the service.”[166] A sexual and reproductive health care administrator working for an NGO remarked, “If I lived in Idlib and I got corona and they told me that I have to go to the isolation center for 15 days, I would not go. My husband will divorce me, and my family will abandon me. We know the stories about what happens in Syria and what it means for a woman … a young or old girl, married or unmarried, to sleep 15 days outside her home.”[167] 

Vaccine skepticism has reportedly intensified the impact of the current wave of the virus in Idlib, where there have been reports of between 1,000 to 1,500 infections a day.[168] Even among medical staff in Idlib, there was mistrust in the vaccine, leading some organizations to threaten not to renew the contracts of unvaccinated doctors.[169] A former field doctor who now works in an administrative role for a health NGO in Idlib reported that acceptance of the vaccine has improved over time in Idlib and that larger segments of the population have turned out to receive vaccines.[170] However, the Türkiye Health Cluster, which provides cross-border aid to areas of Idlib and Aleppo outside the control of the Syrian government, reports that the vaccinated population is only around 1 percent.[171] The WHO reports that, as of November 12, 2021, 176,360 people in northwest Syria had received at least one dose of vaccine.[172]

COVID-19 in Turkish-Controlled Areas

An NGO administrator based in Gaziantep observed that, from the onset of COVID-19, health workers “started monitoring deaths at home…. There are a good number of people who died at home, and this is a serious matter that may indicate the inability of people to reach health facilities during that period.”[173]  Syrians who suspect that they have COVID-19 may avoid isolation centers for multiple reasons, leaving response programs and resources underutilized. An administrator in a health facility in A’zaz explained, “Despite the establishment of these hospitals and projects, most people are treated at home.”[174] In Turkish-controlled areas, COVID-19 patients do not have access to quarantine centers and ventilators due to limited availability. An administrator in a health facility indicated that, instead, patients requiring ventilators must travel to other governorates in northern Syria or to areas controlled by the Syrian government to receive treatment.[175]

The change in donor focus reportedly triggered a shift in staffing, as physicians from other specialties were taking positions in COVID-19 centers. A respondent in A’zaz noted, “We have isolation centers, but we don’t have infectious disease specialists,” adding, “These centers are often run by a general or thoracic doctor, or a doctor with a completely unrelated specialty.”[176]

Respondents indicated that news about the vaccine reaches people via social media platforms laden with conspiracy theories, which may have contributed to the low demand for vaccines in Turkish-controlled areas.[177] A doctor from A’zaz described the vaccine hesitancy, saying, “There was a two-month vaccination campaign in the north. Not many people accepted it, but it was implemented.”[178]

“People used to tell me [while I was giving a] training, ‘Should we be afraid of this small virus, or the chemical weapons above our heads, or the bombing? Bashar [President Assad] has tried everything on us. Let the virus come and kill us all.’”

Health care worker in Idlib

Social Behavior and Lack of Adherence to Public Health Guidelines

The populations of northern Syria, though divided among different regions of control, reportedly share a widespread desensitization to the danger of COVID-19. A respondent observed that social distancing and mask wearing is practically nonexistent, explaining that some people believe that the virus is no more deadly than the flu or common cold.[179] However, others report that the population has become numb to the threat of COVID-19 after a decade of horrific, and often indiscriminate, violence.

A health care worker in Idlib recounted, “People used to tell me [while I was giving a] training, ‘Should we be afraid of this small virus, or the chemical weapons above our heads, or the bombing? Bashar [President Assad] has tried everything on us. Let the virus come and kill us all.’”[180] An administrator from a health facility in Deir Ezzor remarked that throughout northern Syria, fatalism has set in: “People have forgotten that there is such a thing as corona during the past months. He who dies, dies, and he who gets better, gets better.”[181]

An administrator at a health services NGO in Idlib ascribed public complacency about COVID-19 to early successes in combatting the disease following dire warnings from the heath sector.[182] A health care provider in Idlib opined that the impact of the first wave of COVID-19 was less severe than anticipated, in part because of restrictions on entering Idlib governorate that helped curb the spread.[183] In Idlib, the early warning and vaccination teams responded quickly and effectively to the initial wave of cases. The health services administrator remembered,“In March 2020, the College of Medicine launched a wide campaign, visited homes, distributed brochures, and gave lectures in mosques. Many organizations carried out a big campaign against this illness.”[184] Campaigns like these, led by medical schools and NGOs, have been effective in lieu of mandatory COVID-19 prevention and isolation policies, which were not enforced in either northwest or northeast Syria and led to a lack of engagement from local communities.[185]

Legal and Policy Analysis

Syria, Türkiye, and the non-state armed groups in northern Syria are bound by international legal obligations to provide for the right to health and to humanitarian assistance for populations under their control. In addition to their obligations under international human rights law, discussed below, both Syria and Türkiye were among the countries that voted to adopt the Universal Declaration of Human Rights,^[186] which includes the right to life (Article 3) and the right to a standard of living adequate for “health and well-being,” including medical care (Article 25.1). Physicians for Human Rights (PHR) also recalls the ethical obligations of donors and the humanitarian organizations that carry out their work to promote the right to health by providing assistance without discriminatory effect. This includes the duty to provide care to the most vulnerable, including women and the disabled.

The Right to Humanitarian Assistance

The parties to the conflict in Syria must allow for delivery of humanitarian aid in areas under their control and refrain from impeding access to health care. Civilians in areas of armed conflict have a right to receive humanitarian aid, including medical and other supplies essential to survival.[187] International humanitarian law allocates primary responsibility for meeting civilian needs to the state or party that controls the territory in which the civilians are located.[188] Multiple UN Security Council resolutions have indicated that organized armed groups which exercise effective control over territory and carry out administrative and public functions are responsible for protecting the rights of civilians in the territories they control. [189] For example, in Sudan, Resolution 1574 called on the Justice and Equality Movement and the Sudanese Liberation Army – both opposition groups holding territory – to uphold human rights; in the Democratic Republic of the Congo, Resolution 1376 called on all parties, particularly in “territories under the control of the rebel groups,” to end human rights violations and Resolution 1417 identified the opposition group Rassemblement Congolais pour la Democratie-Goma, as the “de facto authority” responsible  for ending human rights violations in the territory it holds.[190] In short, a non-state armed group that is organized and exercises administrative control over territory, as exists in northwest Syria, has the same duties as a government party to the conflict.[191]

If a government or another party with the responsibility to meet essential civilian needs fails to do so, humanitarian organizations and other states can offer to provide relief, as long as they are impartial in character and give priority to those in most urgent need of care.[192] The affected state must consent to delivery of humanitarian assistance to civilian populations in need. However, a state may not withhold consent arbitrarily.[193] The Security Council may also adopt a binding decision permitting UN agencies and their humanitarian partners to deliver aid. In Syria, such a decision was made in 2014, when Security Council Resolution 2165 first authorized UN humanitarian agencies and their partners to deliver humanitarian assistance to Syria across conflict lines – meaning from territory held by one party into another – and through border crossings with Iraq, Jordan, and Türkiye. These UN crossings did not require the consent of the Syrian government or other parties to the conflict.[194] Seven years after establishing the four border crossings, Russia, with the assistance of China, has used its veto power on the Security Council to reduce the UN authorization to one border crossing, Bab al-Hawa.

International Human Rights Law

The Syrian government is a party to the International Covenant on Civil and Political Rights (ICCPR),^[195] which provides for the right to life (Article 6) and the International Covenant on Economic, Social and Cultural Rights (ICESCR), [196] which provides for the right to health (Article 12).[197] The Turkish government is party to the ICCPR and the ICESCR,[198] in addition to the Convention on the Rights of Persons with Disabilities,[199] and therefore may be responsible under international law for upholding these rights in the two enclaves in northern Syria which it controls.[200] Non-state actors must prevent violations of the right to health to the extent that they exercise territorial and administrative control.

The Right to Health

Critically, the health systems described in this report fail to meet the standards established for the right to health as described in the ICESCR. The UN Committee on Economic, Social and Cultural Rights (CESCR) has stated that health is a fundamental human right indispensable for the exercise of other human rights. The right to health imposes four essential standards on health care services: availability, accessibility, acceptability, and quality.[201] The CESCR monitors the implementation of the treaty and has stated that parties must ensure, at the very least, “minimum essential levels” of each right, including the right to health.[202] Health care systems in each area discussed in this report are highly fragmented to a degree that effectively violates Article 12(d), “The creation of conditions which would assure to all medical service and medical attention in the event of sickness.” Instead, services are clustered in one geographic area, while most areas are effectively deprived of service because of the difficulties with transportation and security.

The ICESCR requires signatories to “to take steps” to the maximum of their available resources to achieve progressively the full realization of the right to health (Article 2.1). Regardless of the resources available, however, the “non-discrimination” clause of the ICESCR (Article 2.2) applies, providing that the rights in the covenant “will be exercised without discrimination of any kind as to race, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”[203] The Committee has clarified that this means that health facilities, goods, and services must be “accessible to everyone without discrimination.”[204] The inequities described in this report within each area and compared with other parts of Syria overall make clear that health care is currently provided unequally, to the extent it is being provided at all. For example, in 2019, pro-government governorates received greater health care staffing support than those in areas retaken by the government.[205] In 2020, the annual WHO survey listed seven public hospitals in Deir Ezzor governorate, but over half are nonfunctioning, and the other three are considered “partially functioning.”[206] In Raqqa, three of the four public hospitals are partially functioning, and one is nonfunctioning, while in al-Hasakah province, the only fully functioning hospital is in al-Qamishli, a city in an area known to support the Syrian government. In Idlib, all four public hospitals are considered nonfunctional.[207] A different 2020 WHO report on public health centers in Syria found that 65 percent of the less than 6 percent of health centers that were “fully functioning” were located in Aleppo, the majority of which is controlled by the Syrian government.[208] In comparison, the majority of health centers in every government-controlled governorate, except for Dara’a, were “fully functioning,” and less than 13 percent of health centers were “non-functioning.” Of the total number of non-functioning health centers in Syria (553), 73 percent were in northern governorates.  In northern Syria, the Syrian government’s apparent policy of impeding delivery of humanitarian assistance and its documented attacks on health care facilities and personnel have effectively limited access to health care, as has the Turkish government’s patchwork of regulations.

Conclusion

Physicians for Human Rights’ (PHR) research on the health systems of non-government-controlled regions of Syria reveals extreme disparities in health care among northwest Syria, northeast Syria, and Turkish-controlled areas. The right to health is being violated by the failure of all those providing aid – including humanitarian actors and donors – to ensure minimum standards for health care in crises.

Many factors contribute to the current desperate state of the health systems – or lack of systems altogether – in northern Syria. The COVID-19 pandemic has placed enormous additional strain on health care actors. The Syrian government’s decade-long policy of targeting medical facilities for destruction and its persecution and arbitrary detention of health care workers has led to a decrease in both health care workforce and infrastructure. The lack of political will and consensus at the UN Security Council has resulted in greatly diminished humanitarian assistance and closure of access points. The political instability in northwest, northeast, and Turkish-controlled areas of Syria has resulted in a dangerous absence of a coordinated health response and a patchwork of unaccountable and under-resourced systems. While physical attacks against facilities and personnel are ongoing, this must not obscure the structural violence against public health inherent to these health governance systems, regardless of the political entity in charge.

Each area faces public health emergencies caused by insufficient and unevenly distributed health facilities, critical shortages of qualified, specialized health care workers, and lack of reliable and affordable access to medical equipment and supplies, especially medications. Women, girls, and people living with disabilities are disproportionately impacted by lack of access. Conflict and displacement have resulted in psychological trauma, and increasing levels of poverty compound the health care crisis and create further obstacles to health-seeking behaviors and adherence to COVID-19 prevention measures. The population’s mistrust of government services following years of atrocities, together with the government’s demonstrated lack of will and capacity, make it unlikely that cross-line aid will be effective in the near future. These challenges have severely impacted the availability, accessibility, acceptability, and quality of health care in each region and pose a serious threat to the well-being of millions of Syrians in the north.

The cessation of all attacks against health care, by all parties to the conflict, is a fundamental requirement for any meaningful improvement in health services in northern Syria. The Syrian government’s 10-year campaign to systematically target health facilities and health care workers, as well as to impede the delivery of humanitarian aid to non-government-controlled areas, remains one of the biggest reasons for the health crises facing northern Syria. The persistent threat of violence deters long-term planning and investment in health care and will likely continue to fuel the exodus of workers from the health sector.

In the meantime, the COVID-19 pandemic presents an existential challenge to the health systems in northwest Syria, northeast Syria, and Turkish-controlled areas. All regions lack the capacity to manage outbreaks of COVID-19 without sacrificing the quality and availability of other health services. In addition to unpredictable funding and lack of vital COVID-19 supplies, including vaccines, the lack of adherence to public health guidelines among the general population threatens to undermine the COVID-19 response further. Finding ways to support health facilities and health workers and addressing misinformation and desensitization is essential for fostering trust in the health sector and strengthening its capacity to address the growing COVID-19 emergency.

Respondents in northwest Syria indicated that a campaign by the College of Medicine in Idlib was effective in combatting the spread of the virus in the first wave of COVID-19 there. Generally, bottom-up approaches, such as including local leaders in health decision-making, were effective in increasing community buy-in. Respondents in northeast Syria indicated that local authorities could have played a larger role in setting and enforcing COVID-19 prevention and treatment policies to protect the community and suggested the use of accountability frameworks in program design and implementation to ensure the right to health is being met in these areas. In both northwest and northeast Syria, the local health authorities must be able to exert more leadership on this issue; advocacy with international donors would ensure the delivery of much-needed supplies. Fair distribution of vaccines, testing facilities, and COVID-19 treatment centers would help reinforce local health authorities’ legitimacy and gain them trust in their communities. This could lower other reported barriers to adherence, such as poverty and low community expectations of the local health system. Increased advocacy and communication with international donors are needed to ensure improvements in health system functioning, as evidence suggests that empowering the community without corresponding changes in the system sabotages the trust and relationship-building purpose of community engagement efforts, resulting in poor individual health outcomes.

The health workers and experts interviewed by PHR emphasized that, for planning and staffing purposes, permanent solutions to the lack of medical supplies and services are necessary to ensure regular availability of, and access to, adequate health care. Given the obstacles to cross-line humanitarian assistance between the Syrian government and non-government-held territory – northwest Syria, northeast Syria, and Turkish-controlled areas – efficient delivery of humanitarian assistance to northern Syria must include all possible options to meet population needs. The crossing point at Bab al-Hawa is insufficient to meet the needs of all three regions, and the practice of renewing the border crossings on a six-month basis is detrimental to medium- and long-term planning. For example, the majority of the COVAX vaccines destined for northern Syria have entered through Baba al-Hawa, but in the future it will be very difficult to engage in a global vaccine distribution mechanism if the health actors are unable to plan more than six months ahead of time.[209] Ensuring direct, steady access to humanitarian assistance is an essential step to immediately improving the capacity of the health sectors in northern Syria to respond to the COVID-19 pandemic and address other health emergencies. Local health care staff have reported that uncertainty concerning the renewal of Resolution 2585 has been deeply demoralizing, with health care workers choosing to leave out of frustration and lack of certainty. The UN should extend future resolutions for much longer timeframes, but no less than a year.

Recommendations

Considering the profound and ongoing health disparities among civilians in northern Syria – including in northwest Syria, northeast Syria, and Turkish-controlled areas – and the threat of the multiple waves of COVID-19 to internally-displaced populations throughout Syria and the health systems trying to support them, 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 and broader humanitarian health 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 and assistance (aid distribution) in Syria.

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

To Donors, Humanitarian Actors, and all Parties to the Conflict:

• Continue to fund and support local health systems, including local NGOs, coordinating bodies, and health care facilities that hire health care providers; 
• Provide more financial support, including technical support, for sustainable health sector coordination and to avoid inequitable distribution of health services;
• Provide more support for infrastructure improvements to buildings that are not accessible to those living with physical disabilities;
• Support health facilities and health workers in addressing misinformation and desensitization to foster trust in the health sector and strengthen its capacity to address the growing COVID-19 emergency;
• Make promoting the right to health the goal of all programming in northern Syria; and
• Promote leadership of local authorities in health decision-making to increase community buy-in, reinforce local health authorities’ legitimacy, and gain trust in their communities.

To the Syrian Arab Republic:

• Comply with minimum standards for coordination of humanitarian health system rehabilitation to avoid inequitable access to health care; 
• Cease all attacks on health care and ensure the protection of health care workers guaranteed under international humanitarian law; 
• Adopt transparent measures to prevent diversion of assistance and provide donors with accounts of aid distribution in areas under the control of the Syrian government, including COVID-19 access to training, testing, PPE, equipment, treatment, and vaccines;
• Ensure that COVID-19 vaccines are delivered equitably to all areas of control in Syria, particularly emphasizing that they reach the most vulnerable populations (i.e., health care workers, older people, and people who have underlying health conditions); and
• In areas like northeast Syria, where vaccine hesitancy is high due to public distrust of the Syrian government, administer the vaccine through neutral third-party actors to increase likelihood of vaccine acceptance.

To the Autonomous Administration of North and East Syria, the Syrian Interim Government, the Salvation Government, and the Turkish Government:

• Ensure that public sector services are available for all populations, equitably distributed geographically, accessible, and at a level to meet community needs;
• Promote coordination within the health governance sector by engaging local actors, including NGOs, UN agencies, and donors;
• Empower community-led initiatives to increase the number of ground-up approaches to health care system development to reflect patient populations’ needs and desires; and
• Prioritize accessibility and availability of health care for the physically disabled and for women. 

To the Turkish Government:

• Ease regulations to allow more NGOs to operate across Turkish-controlled areas, as well as northwest Syria and northeast Syria;
• Allow for the flow of medical supplies, including with regard to COVID-19; and
• Uphold international human rights treaty obligations, including the right to life and the right to health in the territories under Turkish control.

To Donors

• Endorse the humanitarian charter and the minimum standards for health system coordination;
• Invest in health services across northern Syria based on population needs and in areas with demonstrated disparities (i.e. based on the UN Humanitarian Needs Assessment Programme) and ensure they reflect the needs of women and the physically disabled in order to guarantee the right to health;
• Preserve and sustain COVID-19-related funding, as long as it is a public health emergency;
• Monitor aid delivery and distribution carefully to avoid diversion and neglect in northern Syria; and
• Scale up funding and resources for the most basic health services and humanitarian assistance in northeast Syria, including in Raqqa and Deir Ezzor.

To the UN Security Council and UN Member States:

• Reopen the Bab al-Salam and al-Yarubiya border crossings to meet the demonstrated need of the population, considering the failing health system and the COVID-19 pandemic;
• Authorize the renewal of cross-border resolution 2165 (in January 2022) to maintain the Bab al-Hawa border crossing in northwest Syria beyond one year;
• Ensure the equitable distribution of COVID-19 vaccines to all areas of control in Syria, particularly emphasizing that they reach the most vulnerable populations (i.e. health care workers, older people, and people with underlying health conditions);
• Place pressure on the Syrian government to ensure the delivery of aid and allocation of health services so that organizations such as the World Health Organization and other UN agencies, international NGOs, and local actors can reach populations in a neutral, effective, and equitable manner;
• Call on the Syrian government and its allies, as well as non-state actors, to stop assaulting health care facilities in violation of international humanitarian law and human rights law; and
• Insist on accountability for previous and ongoing violations of civilians’ right to health across Syria, particularly in areas retaken by the Syrian government.

To the World Health Organization:

• Enforce the Sphere Minimum Standards for coordination of humanitarian health system rehabilitation, including accountable and transparent processes for monitoring;
• Monitor coordination practices and report to donors;
• Track the rebuilding and rehabilitation of facilities to ensure they reflect the needs of women and the physically disabled in order to guarantee those groups’ right to health;
• Demand protection of health care workers and facilities, including cessation of airstrikes;
• Deliver medication and supplies to northern Syria equitably and improve trust-building measures to reduce barriers to accessing services; and
• Release regular reports on COVID-19 to provide timely disease surveillance data for Syria.

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Acknowledgments

This report was written by Physicians for Human Rights (PHR) staff members Houssam al-Nahhas, MD, MPH, MENA researcher (November 2020—August 2021); Andrew Moran, Syria research and investigations associate; and an anonymous author with extensive knowledge of attacks on health care. 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. Diana Rayes, MHS, doctoral student, Department of International Health, Johns Hopkins Bloomberg School of Public Health, contributed to the writing and conducted interviews. Joseph Leone, former research and investigations fellow, contributed to the conceptualization of the research. MENA interns Samantha Scheer and an anonymous MENA intern provided research assistance.

PHR leadership and staff contributed to the writing and editing of this report, including Michele Heisler, MD, MPA, medical director; Donna McKay, MA, executive director; Karen Naimer, JD, LLM, MA, director of programs; Michael Payne, deputy director of advocacy; and Susannah Sirkin, MEd, director of policy and senior advisor.

The report benefited from review by Aula Abbara, MBBS, DTMH, MD, consultant in infectious diseases and acute medicine and honorary senior clinical lecturer at Imperial College, London; Mohammad Darwish, MD, MPH, associate faculty at the Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health; Kathleen M. Foley, MD, attending neurologist at Memorial Sloan-Kettering Cancer Center and secretary of the PHR Board of Directors; and Justine McGowan, senior research lead for the Institute on Inequalities in Global Health, University of Southern California. It was reviewed, edited, and prepared for publication by Claudia Rader, MS, senior communications manager, with assistance from Abigail Daly, communications intern. Hannah Dunphy, MA, digital communications manager, prepared the digital presentation.

PHR would like to thank MedGlobal for sharing images for inclusion in this report. PHR is grateful to Ali Barazi and his associates for translation services. PHR is especially thankful to the health care and humanitarian aid workers and health experts inside Syria and beyond who shared their experiences and knowledge about the health situation in northern Syria through interviews.

This report is supported in part by funding from the German Federal Foreign Office’s Institute für Auslandsbeziehungen, through the zivik Funding Programme. 

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Annex 1

Major Ceasefire Agreements

Date	Region	Relevant Actors	Details	Mediators
May 4, 2017	All opposition-held area of Syria	All parties to the hostilities	Iran, Russia, and Türkiye – guarantors of a putative ceasefire in Syria – signed a memorandum outlining the creation of “de-escalation areas,” the political framework in which the first battles ending in cease-fire agreements in opposition-held territory took place.[210]	Iran, Russia, and Türkiye
September 17, 2018	Idlib	Türkiye, Syrian government, Hayat Tahrir al-Sham (HTS), Russia	The Syrian government’s attempt to retake Idlib from opposition groups led to a ceasefire negotiated between Türkiye and Russia. The ceasefire called for the creation of a 15–20 km (9.3–12.4 mile) demilitarized zone within opposition-controlled Idlib. “Radical militants” were required to withdraw and allow Turkish and Russian forces to patrol the demilitarized zone. HTS and the Syrian government were not included in the original negotiations.[211]	Russia and Türkiye
January 10, 2019	Idlib	HTS, Turkish-backed rebels	HTS and the National Liberation Front (NLF) – a loose alliance of Turkish-backed rebels – agreed to a ceasefire after HTS swept through NLF-held territory in Idlib. Though the NLF was allowed to remain in areas not taken by HTS, the HTS-affiliated Salvation Government took over civil control for all areas.[212]	Party Negotiated
October 17, 2019	Northeast Syria	Syrian Democratic Forces (SDF), Türkiye, Syrian National Army (SNA)	On October 9, 2019, Türkiye, in coordination with the SNA, launched Operation Peace Spring to expel the SDF from areas near the Turkish border. Fighting ended when the United States negotiated a ceasefire with Türkiye that led to the withdrawal of the SDF from a large region in northeast Syria that then became a part of the Turkish-controlled areas.[213]	United States
March 5, 2020	Idlib	Türkiye, Syrian government, HTS	In January 2020, the Syrian government intensified its campaign to retake opposition-controlled Idlib. The escalation, which included direct fighting between the Turkish military and Syrian government forces, ended with a ceasefire that called for joint Turkish-Russian patrols of the M4 highway that cuts through Idlib.[214]	Russia and Türkiye
February 2, 2021	Northeast Syria	SDF, Syrian government	The SDF laid siege to Syrian government-controlled neighborhoods of al-Hasakah city. After 20 days, the two sides agreed to a ceasefire that included lifting the siege.[215]	Russia

Endnotes

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[1] While Physicians for Human Rights (PHR) is aware of the lack of political cohesion and struggles for military dominance within each area, this report adopts the construct of three main geographical areas, since both respondents and aid agencies conceive of aid delivery in this way.

[2] Office for the Coordination of Humanitarian Affairs (OCHA), “Syria Cross-border Humanitarian Fund 2021 Second Standard Allocation Strategy Paper,” November 15, 2021, https://www.humanitarianresponse.info/en/operations/stima/document/schf-2021-second-standard-allocation-sa2-allocation-strategy-paper.

[3] International Rescue Committee, et al., “Reopen Al Yarubiyah crossing into Syria: Open Letter to the United Nations Security Council,” June 23, 2020, https://reliefweb.int/report/syrian-arab-republic/reopen-al-yarubiyah-crossing-syria-open-letter-united-nations-security.

[4] UN Secretary-General António Guterres, briefing to the General Assembly (SG/SM/20664), March 30, 2021, https://www.un.org/press/en/2021/sgsm20664.doc.htm.

[5] Humanitarian Needs Assessment Programme (HNAP) Syria, Summer 2020 Report Series Disability Overview, April 7, 2021, https://reliefweb.int/sites/reliefweb.int/files/resources/Syria%20Disability%20Overview%20-%20HNAP%20SUMMER%202020%20REPORT%20SERIES-1.pdf.

[6] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR. Note that PHR randomly assigned alphanumeric codes to all potential interviewees to preserve confidentiality and protect their identities. For an overview of the issue, including pre-conflict percentages, see United Nations Children’s Fund, “An Estimated 200,000 Pregnant Women in Syria in Need of Urgent Care, Warns UNFPA,” March 19, 2014, https://www.unicef.org/turkey/en/press-releases/estimated-200000-pregnant-women-syria-need-urgent-care-warns-unfpa.

[7] Doctors Without Borders, “Northern Syria’s most severe COVID-19 outbreak overwhelms health system,” October 13, 2021, https://www.doctorswithoutborders.org/what-we-do/news-stories/news/northern-syrias-most-severe-covid-19-outbreak-overwhelms-health-system; Interview with HD_04, Idlib, August 14, 2021, on file with PHR

[8] UN Security Council, “Report of the Secretary-General,” October 21, 2021, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/S_2021_890_E.pdf.

[9] The United Nations Refugee Agency, “Syria emergency,” accessed November 17, 2021, https://www.unhcr.org/en-us/syria-emergency.html.

[10] UN Office for the Coordination of Humanitarian Affairs (OCHA), “2021 Humanitarian Needs Overview: Syrian Arab Republic,” March 31, 2021, https://reliefweb.int/report/syrian-arab-republic/2021-humanitarian-needs-overview-syrian-arab-republic-march-2021.

[11] PHR has confirmed 602 attacks on at least 350 different health care facilities in Syria since 2011, including 149 in Idlib, 30 in Deir Ezzor, seven in Raqqa, and four in al-Hasakah. More than 90 percent of all attacks were carried out by the Syrian government and its allies. Physicians for Human Rights, “Illegal Attacks on Health Care in Syria,” accessed November 3, 2021, http://syriamap.phr.org/#/en.

[12] WHO, “GHC Guidance: People in Need Calculations,” Nov. 3, 2020, https://www.who.int/health-cluster/resources/publications/GHC-PiNGuidance-201104.pdf.

[13] Humanitarian Needs Overview Syria 2021, note 10, 23.

[14] HeRAMS, Second Quarter, 2021 Report, “Turkey Health Cluster for Northwest of Syria, Apr-June 2021,” October 11, 2021, 3,  https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/herams_q2_2021_final.pdf; UN OCHA, “2021 Humanitarian Needs Overview: Syrian Arab Republic,” note 10.

[15] Ibid. HeRAMS classifies health facilities as “fully functioning” when they are open and providing the full package of essential services and “partially functioning” when they are open but not providing the full package of essential services. Of the 459 functioning health facilities, 400 (87.1 percent) were fully functioning and 59 (12.9 percent) were partially functioning.

[16] Ibid, 17.

[17] UN OCHA, “Syrian Arab Republic COVID-19 Response Update No.16,” March 18, 2021, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/covid_response_update_no._16_-_final_draft_180321.pdf.

[18] UN OCHA, “Syrian Arab Republic COVID-19 Response Update No.15,” February 16, 2021, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/covid_response_update_no._15_-_160220.pdf.

[19] PHR, “Obstruction and Denial December 2020 Health System Disparities and COVID-19 in Daraa, Syria,” December 2020, https://phr.org/wp-content/uploads/2020/12/PHR_Obstruction-and-Denial_Health-System-Disparities-and-COVID-19-in-Daraa-Syria_Dec-2020.pdf.

[20] Map of the Syrian Conflict, https://syria.liveuamap.com/.

[21] Balanche, F., “Idlib May Become the Next Gaza Strip,” The Washington Institute for Near East Policy, March 26, 2020, https://www.washingtoninstitute.org/policy-analysis/idlib-may-become-next-gaza-strip.

[22] Aydıntasbas, A., “A new Gaza: Turkey’s border policy in northern Syria,” European Council on Foreign Relations, May 28, 2020, https://ecfr.eu/publication/a_new_gaza_turkeys_border_policy_in_northern_syria/.

[23] Ibid.

[24] The self-declared Islamic State (IS), sometimes referred to as ISIS or ISIL, is also active across northern Syria, but does not hold a significant amount of territory. International Crisis Group, “The Fragility of Northern Syria,” May 26, 2020, https://www.crisisgroup.org/middle-east-north-africa/eastern-mediterranean/syria/fragility-northern-syria.

[25] UN Security Council, Res. 2585, Jul 9, 2021, https://undocs.org/en/S/RES/2585(2021).

[26] UN Security Council, Res. 2533, July 13, 2020, https://undocs.org/en/S/RES/2533(2020).

[27] UN Security Council, Res. 2504, Jan. 10, 2020, https://undocs.org/en/S/RES/2504(2020).

[28] The Syrian Ministry of Health ceased to provide services to Idlib as it lost territory, fully withdrawing from Idlib in 2015. See https://www.bbc.com/news/world-45401474.

[29] Some non-UN humanitarian aid continues to enter through the Semalka border crossing with Iraqi Kurdistan, but reportedly NGOs operating through the crossing face retaliation from the Syrian government and are unable to work in government-controlled areas. The Washington Institute for Near East Policy, “The Assad Regime Has Failed to Restore Full Sovereignty Over Syria,” February 10, 2021, https://www.washingtoninstitute.org/policy-analysis/assad-regime-has-failed-restore-full-sovereignty-over-syria.

[30] Underlying determinants of health outlined by the Right to Health Framework: safe drinking water and adequate sanitation; safe food; adequate nutrition and housing; healthy working and environmental conditions; health-related education and information; gender equality. https://www.ohchr.org/documents/publications/factsheet31.pdf.

[31] Ekzayez, A., “A Model For Rebuilding Infrastructure in Northwestern Syria,” The New Humanitarian, February 19, 2018, https://deeply.thenewhumanitarian.org/peacebuilding/articles/2018/02/19/analysis-a-model-for-rebuilding-infrastructure-in-northwestern-syria.

[32] Five major Syrian health NGOs signed an agreement – the “Code of Conduct for Non-Governmental Organizations Working in Syrian Medical Humanitarian Affairs” – to support health directorates in opposition-controlled areas, including the Idlib Health Directorate. The five NGOs included: Union of Medical Care and Relief Organizations, Syrian American Medical Association, Syrian Expatriates Medical Association, Physicians Across Continents, and Sham Humanitarian Foundation; MIDMAR, “Reinventing State: Health Governance in Syrian Opposition-Held Areas,” November 2019, http://library.fes.de/pdf-files/bueros/beirut/15765.pdf.

[33] Interview with HD_10, London, October 8, 2021, on file with PHR; Enab Baladi, “Health sector in northern Syria… rivalry over administration hinders coordination amid limited funding,” January 5, 2020, https://english.enabbaladi.net/archives/2020/05/health-sector-in-northern-syria-rivalry-over-administration-hinders-coordination-amid-limited-funding/.

[34] Interview with HD_10, London, October 8, 2021, on file with PHR. See also The Middle East Institute, “Ravaged by War, Syria’s Health Care System is Utterly Unprepared for a Pandemic,” April 23, 2020, https://www.mei.edu/publications/ravaged-war-syrias-health-care-system-utterly-unprepared-pandemic. Note that the Syrian government has retaken areas of the northeast to the west of the Euphrates, and has claimed to be providing the area with aid, although UN reporting indicates that only a portion has been successfully distributed.

[35] The Atlantic Council, “The Future of Northeast Syria,” August 13, 2019, https://www.atlanticcouncil.org/wp-content/uploads/2019/11/The-Future-of-Northeast-Syria.pdf.

[36] Heller, S., “Turkish Crackdown on Humanitarians Threatens Aid to Syrians,” The Century Foundation, March 3, 2017, https://tcf.org/content/report/turkish-crackdown-humanitarians-threatens-aid-syrians/?session=1.

[37] Dedoose 9.0, https://www.dedoose.com/.

[38] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[39] Interview with HD_13, Raqqa, August 15, 2021, on file with PHR.

[40] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR and Interview with HD_01, Gaziantep, August 11, 2021, on file with PHR. PHR has documented 190 attacks in the northern region, including, where possible, attribution of the perpetrator. PHR, “Illegal Attacks on Health Care in Syria,” http://syriamap.phr.org/.

[41] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[42] Ibid.

[43] Ibid.

[44] As described in Table 1, the Syrian Democratic Forces are the Kurdish-affiliated army supporting the Autonomous Administration of Northeast Syria, which allied with the Syrian government to protect its territory from the Turkish military after the latter began to occupy territory inside of northern Syria.

[45] PHR, “Illegal Attacks on Health Care in Syria,” http://syriamap.phr.org/.

[46] Interview with HD_23, Idlib, October 13, 2021, on file with PHR.

[47] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[48] UN OCHA, “2021 Humanitarian Needs Overview: Syrian Arab Republic,” March 31, 2021, https://reliefweb.int/sites/reliefweb.int/files/resources/syria_2021_humanitarian_needs_overview.pdf.

[49] The distribution of aid to government-regained areas throughout Syria is reportedly insufficient. While outside the scope of this report, this merits serious investigation and if true, international accountability for governmental diversion of assistance.

[50] Articles 23 and 59 of the Fourth Geneva Convention of 1949 (GC IV) and Articles 69–71 of Additional Protocol I of 1977 (AP I) apply to international armed conflict. In non-international conflicts, like the one in Syria, Common Article 3(2) of the Geneva Conventions of 1949 and Article 18 of Additional Protocol II of 1977 (AP II) apply.

[51] UN Security Council, “Review of alternative modalities for the border crossing of Ya‘rubiyah,” February 21, 2020, S/2020/139, paragraph 14, https://reliefweb.int/sites/reliefweb.int/files/resources/S_2020_139_E.pdf.

[52] UN Security Council Resolution 2165, paragraph two, July 14, 2014, http://unscr.com/en/resolutions/doc/2165. For a brief history of the border crossings and the relevant Security Council resolutions, see Natasha Hall, “The Implications of the UN Cross-Border Vote in Syria,” Center for Strategic and International Studies, June 4 2020, https://www.csis.org/analysis/implications-un-cross-border-vote-syria.

[53] Before the Syrian government takeover of the south in 2018, which led to its official closure in 2020, the al-Ramtha border crossing provided aid that reached nearly two million people in 2017 and an estimated 342,000 in 2018 in southern governorates, including Daraa, Quneitra, Al-Sweida, and Rural Damascus. UN OCHA, “Southern Syria: 4W Interactive Dashboard,” accessed November 3, 2021, https://www.humanitarianresponse.info/en/operations/jordan-cross-border/southern-syria-4w-interactive-dashboard.

[54] Rass, A., “For Millions of Civilians, Syria’s Bab al-Hawa Humanitarian Crossing is a Crucial Lifeline,” Physicians for Human Rights, March 27, 2021, https://phr.org/our-work/resources/for-millions-of-civilians-syrias-bab-al-hawa-humanitarian-crossing-is-a-crucial-lifeline/.

[55] PHR, “Obstruction and Denial December 2020 Health System Disparities and COVID-19 in Daraa, Syria,” December 2020, https://phr.org/wp-content/uploads/2020/12/PHR_Obstruction-and-Denial_Health-System-Disparities-and-COVID-19-in-Daraa-Syria_Dec-2020.pdf.

[56] The World Health Organization recommended minimum standard for care is 1 doctor per 1,000 people and 18 hospital beds for every 10,000 people. United Nations Security Council, “Review of United Nations humanitarian cross-line and cross-border operations,” May 14, 2020, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_2020_401.pdf.

[57] The most recent data collected directly from the Idlib Health Directorate in 2019 indicates there were only 600 physicians providing health care to more than four million people in the governorate. A. Olabi and H. al-Nahhas, “COVID-19 in Fragile States – Barriers and Facilitators to Health Promotion: A Case Study from North West Syria,” Second Syria Health Research Conference, Oct. 30, 2020, Scripted Presentation, on file with PHR.

[58] Interview with HD_13, Raqqa, August 15, 2021, on file with PHR.

[59] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR and interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[60] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[61] PHR, “‘No Place Is Safe for Health Care’: The Attack on Syria’s al-Atareb Hospital,” July 2021, https://phr.org/wp-content/uploads/2021/07/Al-Atareb-Hospital-Attack-PHR-SAMs-Case-Study-July-2021.pdf.

[62] Interview with HD_74, Deir Ezzor, August 25, 2021, on file with PHR and interview with HD_04, Idlib, August 14, 2021, on file with PHR.

[63] Interview with HD_73, Deir Ezzor, August 25, 2021, on file with PHR.

[64] Abbara, A. et al., “Syria’s health system, regional dynamics and future health policy options,” January 2021, unpublished presentation on file with PHR.

[65] International Crisis Group, “Syria: Shoring Up Raqqa’s Shaky Recovery,” November 18, 2021, https://www.crisisgroup.org/middle-east-north-africa/east-mediterranean-mena/syria/229-syria-shoring-raqqas-shaky-recovery.

[66] Interview with HD_70, Deir Ezzor, August 24, 2021, on file with PHR and interview with HD_02, Deir Ezzor, August 23, 2021, on file with PHR. Prior to the January 2020 closing of al-Yarubiya, the northeast humanitarian cluster was part of the UN Whole of Syria system and had a mandate to coordinate with the Damascus humanitarian hub for aid. With al-Yarubiya closed, the mandate of the Northeast Syria Forum is reportedly less clear and information sharing with Damascus may be perceived as dangerous.

[67] Interview with HD_70, Deir Ezzor, August 24, 2021, on file with PHR.

[68] UN OCHA, “2021 Humanitarian Needs Overview: Syrian Arab Republic,” March 31, 2021, https://reliefweb.int/sites/reliefweb.int/files/resources/syria_2021_humanitarian_needs_overview.pdf.

[69] Amnesty International, “Syria: Russian threat to veto renewal of last aid corridor leaves millions at risk of humanitarian catastrophe,” June 25, 2021, https://www.amnesty.org/en/latest/press-release/2021/06/syria-russian-threat-to-veto-renewal-of-last-aid-corridor-leaves-millions-at-risk-of-humanitarian-catastrophe/.

[70] Hall, N., “The Implications of the UN Cross-Border Vote in Syria,” June 4, 2021, https://www.csis.org/analysis/implications-un-cross-border-vote-syria.

[71] Ibid.

[72] UN Security Council, “Review of alternative modalities for the border crossing of Ya‘rubiyah,” February 21, 2020, paragraph 14, https://reliefweb.int/sites/reliefweb.int/files/resources/S_2020_139_E.pdf.

[73] UN Secretary General’s report, S/2020/401, “Review of United Nations humanitarian cross-line and cross-border operations,” May 14, 2020, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/s_2020_401.pdf.

[74] Interview with HD_73, Deir Ezzor, August 25, 2021, on file with PHR.

[75] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[76] Interview with HD_73, Deir Ezzor, August 25, 2021, on file with PHR; REACH, “Syria: Deir-ez-Zor: Situation Overview and Sub-district Profiles, June 2018,” June 29, 2018, https://reliefweb.int/report/syrian-arab-republic/syria-deir-ez-zor-situation-overview-and-sub-district-profiles-june-2018.

[77] Fouad, M., 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, March 14, 2017, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30741-9/fulltext.

[78] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[79] Ibid.

[80] Tribal politics in northeastern Syria reportedly contribute to security and protection risks for health care workers not endorsed by the tribes. Personal communication, expert on northeast Syrian health system, November 6, 2021 (on file with PHR). 

[81] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[82] The Free Syrian Army is now known as the Syrian National Army (SNA).

[83] Interview with HD_13, Raqqa, August 15, 2021, on file with PHR.

[84] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[85] Interview with HD_74, Deir Ezzor, August 25, 2021, on file with PHR.

[86] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[87] Interview with HD_72, A’zaz, August 25, 2021, on file with PHR.

[88] UN OCHA, “Recent Developments in Northwest Syria and RATAA: Situation Report #27,” June 18, 2021, https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/nw_syria_and_rataa_situation_report_20210618.pdf.

[89] The World Food Programme successfully completed a cross-line delivery of food and nutrition assistance on August 31, 2021 from government-controlled Aleppo city, Aleppo governorate, to a warehouse in opposition-controlled Sarmada city, Idlib governorate. United Nations Security Council, Implementation of Security Council resolutions 2139 (2014), 2165 (2014), 2191 (2014), 2258 (2015), 2332 (2016), 2393 (2017), 2401 (2018), 2449 (2018), 2504 (2020), 2533 (2020) and 2585 (2021), S/2021/890, October 21, 2021, 10/21/21, paragraph 49, https://documents-dds-ny.un.org/doc/UNDOC/GEN/N21/287/12/PDF/N2128712.pdf?OpenElement.

[90] Center for Operational Analysis and Research, “Cross-line convoy sparks cross-border conjecture,” September 6, 2021, https://coar-global.org/2021/09/06/cross-line-convoy-sparks-cross-border-conjecture/.

[91] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[92] United Nations Security Council, “Implementation of Security Council resolutions 2139 (2014), 2165 (2014), 2191 (2014), 2258 (2015), 2332 (2016), 2393 (2017), 2401 (2018), 2449 (2018), 2504 (2020), 2533 (2020) and 2585 (2021), October 21, 2021, Paragraph 66, https://documents-dds-ny.un.org/doc/UNDOC/GEN/N21/287/12/PDF/N2128712.pdf?OpenElement.

[93] Interview with HD_01, Gaziantep, August 11, 2021, on file with PHR.

[94] Interview with HD_07, Idlib, August 6, 2021, on file with PHR; PHR, “‘No Place Is Safe for Health Care’: The Attack on Syria’s al-Atareb Hospital,” July 2021, https://phr.org/issues/health-under-attack/attacks-in-syria/al-atareb-surgical-hospital-no-place-in-syria-is-safe-for-health-care/.

[95] The White Helmets, also known as the Syrian Civil Defense, is an organization that consists of a group of 3,000 volunteers who save lives through providing emergency response and early recovery operations in opposition-controlled areas in Syria. https://www.syriacivildefence.org/en/; see also https://twitter.com/syriacivildef/status/1237762465049587713?lang=en.

[96] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[97] Interview with HD_01, Gaziantep, August 11, 2021, on file with PHR.

[98] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[99] A health care worker in A’zaz explained that all health projects in Turkish-controlled areas require a contract between the implementing organization and the Turkish health directorate. Interview with HD_72, A’zaz, August 25, 2021, on file with PHR.

[100] Ibid.

[101] Ibid.

[102] Interview with HD_21, A’zaz, Aug. 24, 2021, on file with PHR.

[103] Interview with HD_72, A’zaz, August 25, 2021, on file with PHR.

[104] Interview with HD_07, Idlib, August 6, 2021, on file with PHR; interview with HD_72, A’zaz, August 25, 2021, on file with PHR; interview with HD_05, A’zaz, August 26, 2021, on file with PHR.

[105] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR.

[106] Al-Dimashqi, Y. and F. Massena, “For Many Syrian Women, Healthcare is a Matter of Geography,” The New Humanitarian, August 16, 2017,  https://deeply.thenewhumanitarian.org/syria/articles/2017/08/16/for-many-syrian-women-healthcare-is-a-matter-of-geography.

[107] Akik, C., et al.  “Responding to health needs of women, children and adolescents within Syria during conflict: intervention coverage, challenges and adaptations,” Conflict and health, 14, May 29, 2020, 1-19. https://conflictandhealth.biomedcentral.com/articles/10.1186/s13031-020-00263-3.

[108] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[109] Rates of child marriage have reportedly risen as a negative coping mechanism. This respondent reported hearing stories of families giving young girls hormonal treatments to accelerate puberty so that they can enter the “marriage market” sooner.Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[110] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.  

[111] Ibid. See also C. Akik et al., note 107 (“Family planning was reported to have been overlooked in the early phases of the response, and took time to be re- established, with certain reported geographic discrepancies.”).

[112] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[113] Ibid.

[114] Ibid.

[115] Ibid. For an overview of the issue, see UNFPA, “An Estimated 200,000 Pregnant Women in Syria in Need of Urgent Care, Warns UNFPA,” Press Release, March 19, 2014, https://www.unicef.org/turkey/en/press-releases/estimated-200000-pregnant-women-syria-need-urgent-care-warns-unfpa.

[116] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR.

[117] The Humanitarian Needs Assessment Programme (HNAP) for Syria tracks displacement and return movements, conducts multisectoral assessments, and monitors humanitarian needs inside Syria. The HNAP is implemented through local Syrian NGOs, with technical support from UN agencies.

[118] UN Humanitarian Needs Assessment Programme, “Summer 2020 Report Series Disability Overview, ” April 7, 2021, https://reliefweb.int/sites/reliefweb.int/files/resources/Syria%20Disability%20Overview%20-%20HNAP%20SUMMER%202020%20REPORT%20SERIES-1.pdf.

[119] Shahabi, S. et al., “Nine years of war and internal conflicts in Syria: a call for physical rehabilitation services,” Disability & Society, 36:3, Feb. 22, 2021, 508-512.

[120] UN Humanitarian Needs Assessment Programme, “Disability: Prevalence and Impact: Syrian Arab Republic,” September 2019, https://www.globalprotectioncluster.org/wp-content/uploads/Disability_Prevalence-and-Impact_FINAL-2.pdf.

[121] Interview with HD_01, Gaziantep, August 11, 2021, on file with PHR.

[122] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR.

[123] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR.

[124] In January 2020, the average daily wage for an unskilled laborer in northwest Syria was 1,742 SYP (0.69 USD), meaning a crutch would cost more than a month’s wages. REACH, “Syria – Northwest Syria: Daily wage and employment sectors – January 2020,” January 22, 2020, https://reliefweb.int/sites/reliefweb.int/files/resources/REACH_Syr_Daily_wages_employment_sectors_Jan_20.pdf.

[125] Interview with HD_32, Raqqa, August 15, 2021, on file with PHR.

[126] UN OCHA, “Dashboard, “Organizations Implementing Humanitarian Activities Based Within Syria,” July 2021, http://www.ocha-sy.org/4wspresence2021.html.

[127] For an introduction to the development of the health systems in Syria and the problems they pose, see Abbara, A. et al., “Health System Fragmentation and the Syrian Conflict,” in Everybody’s War, Oxford University Press, 2021.

[128] Interview with HD_10, London, October 8, 2021, on file with PHR.

[129] Ibid.

[130] Ibid.

[131] Interview with HD_18, Gaziantep, September 10, 2021, on file with PHR and interview with HD_05, A’zaz, August 26, 2021, on file with PHR.

[132] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[133] Ibid.

[134] Doctors Without Borders, “Northern Syria’s most severe COVID-19 outbreak overwhelms health system,” October 13, 2021, https://www.doctorswithoutborders.org/what-we-do/news-stories/news/northern-syrias-most-severe-covid-19-outbreak-overwhelms-health-system; Interview with HD_04, Idlib, August 14, 2021, on file with PHR.

[135] UN Meetings Coverage and Press Releases, “Report of the Secretary-General,” October 21, 2021, https://www.securitycouncilreport.org/atf/cf/%7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9%7D/S_2021_890_E.pdf.

[136] UN Meetings Coverage and Press Releases, “Humanitarian Needs in Syria Greater Than Ever, Relief Chief Warns Security Council,” (SC/14638), September 15, 2021, https://www.un.org/press/en/2021/sc14638.doc.htm.

[137] Interview with HD_23, Idlib, October 13, 2021, on file with PHR.

[138] Interview with HD_04, Idlib, August 14, 2021, on file with PHR.

[139] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[140] Interview with HD_23, Idlib, October 13, 2021, on file with PHR.

[141] UN Meetings Coverage and Press Releases, “As Plight of Syrians Worsens, Hunger Reaches Record High, International Community Must Fully Commit to Ending Decade-Old War, Secretary-General Tells General Assembly,” March 30, 2021, https://www.un.org/press/en/2021/sgsm20664.doc.htm.

[142] World Food Programme, Syria Country Office, “Market Price Watch Bulletin,” December 2020 issue 73, . https://docs.wfp.org/api/documents/WFP-0000122982/download/.

[143] Interview with HD_04, Idlib, August 14, 2021, on file with PHR.

[144] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[145] Interview with HD_05, A’zaz, August 26, 2021, on file with PHR.

[146] World Trade Organization, “COVID-19 and trade – Turkey,” accessed November 5, 2021, https://www.wto.org/english/tratop_e/covid19_e/covid_details_by_country_e.htm?country=TUR. While Türkiye terminated the prior export authorization requirements for ventilators, oxygen concentrators, intensive care monitors, and other medical equipment on May 2, 2020, the restrictions on exporting PPE remained. Türkiye

did not approve a temporary export authorization for PPE until March 4, 2021, which expired on August 6, 2021.

[147] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR. Note that, as of November 2021, antiviral pills for treatment of COVID-19 reportedly show promise of managing symptoms. They represent an important possibility for which availability and access must be assured. Meaningful access requires testing capacity, since the pills should only be given to symptomatic people after a positive test. See Rebecca Robbins, “Pfizer Says Its Antiviral Pill Is Highly Effective in Treating Covid,” New York Times, Nov. 5, 2021, https://www.nytimes.com/2021/11/05/health/pfizer-covid-pill.html.

[148] Interview with HD_02, Deir Ezzor, August 23, 2021, on file with PHR.

[149] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[150] Interview with HD_70, Deir Ezzor, August 24, 2021, on file with PHR.

[151] Interview with HD_70, Deir Ezzor, August 24, 2021, on file with PHR.

[152] Interview with HD_02, Deir Ezzor, August 23, 2021, on file with PHR.

[153] Interview with HD_62, Raqqa, October 13, 2021, on file with PHR.

[154] Ibid.

[155] Interview with HD_71, Raqqa, August 24, 2021, on file with PHR.

[156] Interview with HD_75, Deir Ezzor, September 2, 2021, on file with PHR.

[157] Ibid.

[158] WHO, “Update on COVID-19 vaccination in Syria, 12 November 2021,” November 12, 2021, http://www.emro.who.int/syria/news/update-on-covid-19-vaccination-in-syria-12-november-2021.html.

[159] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[160] Interview with HD_23, Idlib, October 13, 2021, on file with PHR.

[161] The Syrian American Medical Society (SAMS) recently reported that despite a 76 percent increase in the availability of oxygen cylinders in northwest Syria since early 2020, their availability is hampered by the logistical challenges of maintaining oxygen generators, procuring spare parts, and transportation over poorly maintained roads. “SAMS Policy Document” https://www.sams-usa.net/wp-content/uploads/2021/11/Policy-document-Oxygen-Gap-in-NWS-V_3.5-Final.pdf.

[162] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[163] Ibid.

[164] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[165] Interview with HD_04, Idlib, August 14, 2021, on file with PHR.

[166] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[167] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[168] Reuters, “Syrians face common enemy across frontlines: surging COVID-19,” Sept. 30, 2021, https://www.reuters.com/world/middle-east/syrians-face-common-enemy-across-frontlines-surging-covid-19-2021-09-30/; see also Fahim, Kareem and Hussam, Ali. “This besieged Syrian province escaped the worst of covid. Then vaccine skepticism crossed the border,” Washington Post, Nov. 2, 2021, https://www.washingtonpost.com/world/2021/11/02/idlib-syria-coronavirus-covid-refugees/.

[169] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[170] Interview with HD_12, Idlib, August 10, 2021, on file with PHR.

[171] Turkey Cross Border Health Cluster (Turkey Hub), “Health Cluster Bulletin Sept-2021,” November 1, 2021, https://www.humanitarianresponse.info/en/operations/stima/document/turkey-health-cluster-bulletin-sept-2021.

[172] WHO, “Update on COVID-19 vaccination in Syria, 12 November 2021,” November 12, 2021, http://www.emro.who.int/syria/news/update-on-covid-19-vaccination-in-syria-12-november-2021.html.

[173] Interview with HD_01, Gaziantep, August 11, 2021, on file with PHR.

[174] Interview with HD_21, A’zaz, August 24, 2021, on file with PHR.

[175] Interview with HD_73, Deir Ezzor, August 25, 2021, on file with PHR.

[176] Interview with HD_72, A’zaz, August 25, 2021, on file with PHR.

[177] Interview with HD_05, A’zaz, August 26, 2021, on file with PHR and interview with HD_21, A’zaz, August 24, 2021, on file with PHR.

[178] Interview with HD_05, A’zaz, August 26, 2021, on file with PHR.

[179] Interview with HD_21, A’zaz, August 24, 2021, on file with PHR.

[180] Interview with HD_14, Gaziantep, August 15, 2021, on file with PHR.

[181] Interview with HD_73, Deir Ezzor, August 25, 2021, on file with PHR.

[182] Interview with HD_21, A’zaz, August 24, 2021, on file with PHR.

[183] Interview with HD_07, Idlib, August 6, 2021, on file with PHR.

[184] Interview with HD_21, A’zaz, August 24, 2021, on file with PHR.

[185] Olabi, A. and H. al-Nahhas, H, “COVID-19 in Fragile States,” note 57.

[186] Universal Declaration of Human Rights, December 10, 1948, Art. 25.

[187] Akande, Dapo and Emanuela-Chiara Gillard. “Arbitrary Withholding of Consent to Hum Relief Operations in Armed Conflict,” International Legal Studies, 92:483 (2016) https://digital-commons.usnwc.edu/cgi/viewcontent.cgi?article=1696&context=ils.

[188] See, e.g., principles 3 and 25, Deng, F., “Guiding Principles on Internal Displacement,” (2004),  .https://www.unhcr.org/en-us/protection/idps/43ce1cff2/guiding-principles-internal-displacement.html.

[189] Increasingly, the UN Security Council has found non-state armed groups to have obligations to the civilian populations they control.  See, e.g., UNSC Res. 1574, pmbl., paragraph 11 (November 19, 2004); UNSC Res. 1376, paragraph 5 (November 9, 2001); UNSC Res. 1417, paragraph 4 (June 14, 2002). See also Walter Kälin (Representative of the Secretary-General), “Report on the Human Rights of Internally Displaced Persons: Addendum: Mission to Georgia,” paragraph 5, UN Doc. E/CN.4/2006/71/Add.7 March 24, 2006.

[190] UNSC Res. 1574, pmbl., para. 11 (November 19, 2004); UNSC Res. 1376, paragraph 5 (November 9, 2001); UNSC Res. 1417, paragraph 4 (June 14, 2002).

[191] Vanhullebusch, M., “Do Non-State Armed Groups Have a Legal Right to Consent to Offers of International Humanitarian Relief?” Journal of Conflict & Security Law, July 2020, 25:2, 317–341 at 324.

[192] Geneva Convention IV, Art 3, No. 2, August 12, 1949.

[193] See, e.g., UN OCHA, “Guiding Principles on Internal Displacement,” Principles 3 and 25, September 2004, https://www.unhcr.org/en-us/protection/idps/43ce1cff2/guiding-principles-internal-displacement.html; Institute of International Law, “Humanitarian Assistance,” 16th Commission, February 9, 2003, https://www.idi-iil.org/app/uploads/2017/06/2003_bru_03_en.pdf; Council of Europe, “Europe’s duty to internally displaced persons,” May 29, 2018, https://www.coe.int/en/web/commissioner/-/europe-s-duty-to-internally-displaced-persons.

[194] UN Security Council Res. 2165, paragraph two (July 14, 2014). For a brief history of the border crossings and the relevant Security Council resolutions, see Hall, N., “The Implications of the UN Cross-Border Vote in Syria,” Center for Strategic and International Studies, June 2020, https://www.csis.org/analysis/implications-un-cross-border-vote-syria.

[195] International Covenant on Civil and Political Rights, December 16, 1966, https://www.ohchr.org/documents/professionalinterest/ccpr.pdf.

[196] International Covenant on Economic, Social and Cultural Rights, December 16, 1966, Art.12, acceded January 3, 1976, https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx.

[197] The Syrian Constitution (2012) provides citizens the right to health, as articulated in Article 22.2: “The state shall protect the health of citizens and provide them with the means of prevention, treatment and medication.” Syrian Arab Republic, “Constitution of the Syrian Arab Republic,” 2012, https://www.ilo.org/dyn/natlex/docs/ELECTRONIC/91436/106031/F- 931434246/constitution2.pdf.

[198] Türkiye ratified both the ICCPR and the ICESCR on September 23, 2003.

[199] Ratified Sept. 28, 2009.

[200]The extraterritorial applicability of international human rights law is subject to intense scholarly and policy debate. Leading scholarship in this area includes Milanovic, M., Extraterritorial Application of Human Rights Treaties: Law, Principles, and Policy, 2011 (Oxford University Press), and Da Costa, K., The Extraterritorial Application of Selected Human Rights Treaties, 2013, (Martinus Nijhoff).

[201] IFHHRO Medical Human Rights, “AAAQ Framework,” https://www.ifhhro.org/topics/aaaq-framework/.

[202] Office of the High Commissioner for Human Rights, “CESCR, General Comment 3: The Nature of States Parties Obligations E/1991/23,” December 14, 1999, https://www.refworld.org/pdfid/4538838e10.pdf.

[203] International Covenant on Economic and Social and Cultural Rights (ICESCR), January 3, 1976, ESR, Art. 2.2, https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx.

[204] Office of the High Commissioner of Human Rights, “CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health” (Art. 12). August 11, 2000, https://www.refworld.org/pdfid/4538838d0.pdf.

[205] The ratio of medical doctors in Daraa, which was retaken by the government, is 1.1 for every 10,000 people. In Damascus, there are 20.3 medical doctors per 10,000 people; in Latakia which traditionally has supported the government, the ratio is 15.3 per 10,000.  HeRAMS Annual Report 2020. See also, PHR,” Obstruction and Denial,” 2020.

[206] HeRAMS Annual Report, January–December 2020, “Public Hospitals in the Syrian Arab Republic,” https://applications.emro.who.int/docs/SYR/EMRLIBSYR286E-eng.pdf?ua=1.

[207] Ibid., but see page 13, “Special Cases,” describing partially functioning hospitals that are staffed by “by non-MoH staff with no information available, where data is being collected by cross-border partners.”

[208] HeRAMS Annual Report, January – December 2020, “Syrian Arab Red Crescent Health Centres in the Syrian Arab Republic,”  https://applications.emro.who.int/docs/syr/EMRLIBSYR285E-eng.pdf?ua=1.

[209] Rass, A., note 54.

[210] Ministry of Foreign Affairs of the Russian Federation, “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.

[211] The Kremlin, “Press statement following Russian-Turkish talks,” September 17, 2018, http://en.kremlin.ru/events/president/news/58574.

[212] Al-Nofal, W., and A. Edelman, “Intra-rebel ceasefire agreement brings HTS offensive to a halt, but expands hardline control in northwest,” Syria Direct, January 10, 2019, https://syriadirect.org/intra-rebel-ceasefire-agreement-brings-hts-offensive-to-a-halt-but-expands-hardline-control-in-northwest/.

[213] Fahim, K., et al., “Syria cease-fire agreement lifts threat of U.S. sanctions while letting Turkey keep buffer zone,” Washington Post, October 17, 2019, https://www.washingtonpost.com/world/pence-arrives-in-turkey-as-us-seeks-to-halt-erdogans-syria-offensive/2019/10/17/55b806aa-f04c-11e9-bb7e-d2026ee0c199_story.html.

[214] Khurshudyan, I. and S.Dadouch, “Russia and Turkey agree to cease-fire in Syria’s Idlib province,” Washington Post, March 5, 2020, https://www.washingtonpost.com/world/russia-and-turkey-agree-to-cease-fire-in-syrias-idlib-province/2020/03/05/037d358c-5e50-11ea-ac50-18701e14e06d_story.html.

[215] Al-Khalidi, S., “U.S. backed Kurds lift siege of Syrian army run enclaves in northeast,” Reuters, February 2, 2021, https://www.reuters.com/article/us-syria-security-northwest/u-s-backed-kurds-lift-siege-of-syrian-army-run-enclaves-in-northeast-idUSKBN2A22KQ.

For professionals who work in sexual violence research and monitoring and evaluation (M&E), engaging with survivors of sexual violence can be a powerful tool for combatting impunity and securing justice. But it can be a double-edged sword, particularly if done in a manner that puts survivors at risk of being re-traumatized. Physicians for Human Rights’ (PHR) Program on Sexual Violence in Conflict Zones has spent the past few months diving into the question of how can you capture the unique and diverse voices of survivors without causing them further trauma and pain?

More humanitarian practitioners are seeing the value of survivors’ voices in guiding humanitarian programming. Survivors can advocate for each other more effectively than anyone else. For practitioners, like PHR, who provide programs to help survivors secure justice, an important way to know whether these programs work may be by engaging with survivors directly. But beyond re-traumatization, other significant risks include stigma, discrimination, and retaliation. That’s why PHR has avoided engaging directly with sexual violence survivors, instead relying on the professionals we work with who support survivors – like health care workers, police officers, and lawyers – to speak to survivor needs.

While this approach has allowed us to avoid survivor re-traumatization, we believe survivors have a critical perspective in developing survivor-centered programs that we should understand. Furthermore, there is diversity of experience among survivors that is important to capture. To address this, we conducted secondary research and spoke to several scholars on the topic to better understand what it would take to ethically engage with survivors in our research and M&E. Here are our five top takeaways: 

1. Think carefully about why you want to engage the survivor.

Before engaging with survivors, ask yourself what your motivation is. Are you looking for survivors’ perspectives to design more survivor-centered or rights-based programming, in which case engagement may be necessary? Or are you simply looking for a quote for a report? In the latter case, engagement, with its attendant risks, might best be avoided. 

If you have a clear purpose for engagement, then think through the following questions:

What information will you need from survivors that you cannot capture from anyone else? If the data you need can be captured elsewhere, then survivors’ testimony should be avoided, given the potential risks to their well-being.

Is this data necessary to achieve your research and/or M&E objectives? If the data is not critical for meeting your goals, then there is no clear reason to engage survivors.

2. The benefits of survivor engagement should outweigh the costs.

The benefits of engaging with sexual violence survivors must be greater than the risks to them. This point emerged in nearly every interview we conducted, and is a central recommendation provided by the World Health Organization in its guiding principles for documenting sexual violence in emergencies. Before engaging with survivors, first check: What are the costs and benefits of engaging for both the survivor and the organization? Engagement should have benefits to the survivor at its core; this tends to be either not clearly defined or de-prioritized altogether. Engagement should also carefully evaluate the potential risks to the survivor. For example, are we gathering data that could put survivors at risk? If so, how can we mitigate such risks? One way to gather these insights might be through a costs/benefits exercise led by survivors themselves, although we could not find any obvious tool that does this – a gap which emerged through our research.

3. Engage survivors as partners in the design of M&E and/or research.

Often, the beneficiaries of programs – the people who count the most – are overlooked and underappreciated in humanitarian programming. Yet survivors of sexual violence can provide unique perspectives grounded in the day-to-day experiences of the very people that programs are designed to support—key for designing survivor-centered or rights-based programming.

One way to elevate survivor voices is to seek their input on the central research question, or on designing data security and confidentiality measures, research tools, goals, and outputs. Ask them: “What are you hoping to see from this research and how can we work together to meet those goals?” Engage with survivors regularly, either one-on-one or by creating a survivor advisory group, ensuring that they provide inputs into the research or M&E process every step of the way.

4. Carefully tailor the size and composition of the interview team to meet the needs of the survivors being interviewed.

It is important to note that survivors are not a monolithic group of individuals. Survivors can be of different genders, different ages – from child to adolescent to adult – and represent many other kinds of diversity. Although our research has focused primarily on adult survivors, it is also critical to understand the differences that exist within this group. Therefore, when considering who should engage with the survivor, our research and interviews have suggested that practitioners ideally work with local implementation NGOs that engage with survivor communities to identify and designate:

• Someone from the same culture and/or shared trauma as the survivor being interviewed, which allows for more effective trust-building;
• Someone with an M&E and/or research background;
• Someone who has interviewed trauma-affected populations in the past (and particularly the survivor type in question); and/or
• Someone who has gained respect and trust within the community of interest.

It may also be worth choosing a physical and/or mental health care professional, but as this is not always possible, all facilitators should be trained in basic psychological first aid.

Finding someone who checks all of these boxes can be difficult, so a team of facilitators may be necessary.

5. Ensure that you work with funders to ensure that survivors’ basic needs are met from a funding/budget perspective.

Engaging with survivors comes with financial costs; for example, you may need to transport survivors to a safe and secure location. Sometimes, a survivor may not want to engage unless they are compensated for their time and support. Humanitarian practitioners should work with funders to set aside adequate funding to support survivors through the engagement process.

More Research Needed

These principles are a starting point, but they have revealed a few key gaps. Little guidance exists on specific mechanisms for engaging with survivors in research and M&E. Also, there appears to be no existing costs/benefits tool centered on sexual violence survivor engagement.

To address these limitations and build on these insights, PHR’s Program on Sexual Violence in Conflict Zones is currently conducting a study to better understand existing methods for engaging with survivors of sexual violence in conflict-ridden, resource-constrained contexts (see where PHR works). We want to identify gaps in current research and practices. And, finally, we hope to develop rigorous, survivor-centered, and trauma-informed methods for ethically engaging survivors of sexual violence in research and M&E initiatives – harnessing their unique and precious perspectives in the effort to secure justice for all survivors of these crimes.

Executive Summary

In March 2011, the Arab Spring movement spread to Syria when civilians across the country began peacefully demonstrating against the government of President Bashar al-Assad. Although the Syrian government tried to signal to the international community that it was responding to the demands of peaceful demonstrators, in reality, it violently cracked down on peaceful protesters.[1] Security forces began brutally suppressing protests and detaining health care workers who treated injured protesters, effectively criminalizing health care. Most of the health care workers detained by the government were forcibly disappeared – they were never charged, and their fate remains unknown; some were released, and an unknown number have died in detention. Enforced disappearance is a crime with multiple victims: in addition to the physical and psychological suffering of the detainees, their families and community are all forced to live with mental anguish and uncertainty about their loved ones’ fate, without access to their remains for proper burial and memorial when they are deceased.

In this report, Physicians for Human Rights (PHR) examines patterns in the Syrian government’s forced disappearance, detention, and abuse of health care workers during the early years of the Syrian uprising. The findings are based on a new data set of 1,685 detentions that occurred in 2011 and 2012, which PHR compiled using data sets provided by the Open Society Justice Initiative, the Syrian Network for Human Rights, and the Violations Documentation Center. The PHR research team systematically reviewed the original data sets to standardize the format, create new variables using information from notes sections, and deduplicate repeated cases. In addition to several examples from previous PHR interviews with physicians detained for providing health care, this report includes a case study of a medical team that operated in Aleppo in 2012. Many of the team’s members were detained by the Syrian government and several were killed while in detention. This newly compiled data and PHR’s analysis illuminate the government’s massive violent crackdown on dissent and its persecution of health care workers who responded to the injured during the initial years of the Syrian crisis.

From the earliest days of the Syrian uprising, the Syrian government targeted health care workers with detention, abuse, and torture for providing medical assistance to those who opposed the regime.

The report reveals that a health care worker’s profession and the reason they were detained appear to have had a significant impact on the outcome of their detention. PHR’s analysis yielded two main findings: health care workers detained for providing medical care experienced worse outcomes than health care workers detained for their political activities, and among detained health care workers, physicians overall experienced better outcomes than non-physicians.

If the Syrian government detained a health care worker for providing medical care to an injured protester, the odds of release for that person were 91 percent lower and the odds of being forcibly disappeared were 550 percent higher compared to the fate of health care workers detained for political reasons. If two health care workers from similar professions were detained in the same place for different reasons, the data show that the one detained for providing health care would have 400 percent higher odds of dying in detention than the person detained for a political reason. Further, while most health care workers experienced poor outcomes, either dying or being forcibly disappeared, the odds that a physician would be released were 143 percent higher than for non-physicians. Physicians were also 52 percent less likely to be forcibly disappeared and 48 percent less likely to die in detention compared to non-physicians. There are many potential explanations for why and how these factors influenced detention outcomes, which this report explores.

Most of the health care workers detained by the government were forcibly disappeared – they were never charged, and their fate remains unknown; some were released, and an unknown number have died in detention.

PHR’s analysis shows that, from the earliest days of the Syrian uprising, the Syrian government targeted health care workers with detention, abuse, and torture for providing medical assistance to those who opposed the regime. The United Nations has estimated that the Syrian government arbitrarily detained or forcibly disappeared at least 100,000 people, among them thousands of health care workers, in contravention of domestic laws, human rights law, and international humanitarian law. As the Syrian conflict moves towards a potential phase of negotiation, it is imperative that the voices of the survivors and missing persons’ families be heard and that they be told the truth about their loved ones’ disappearance. In addition to the need for truth, Syrians deserve justice and accountability for the mass forced disappearance of opponents to the Syrian regime and those who provided care to the sick and wounded according to their ethical and moral duties.

In February 2021, a coalition of five Syrian organizations representing survivors, their families, and family members of the missing drafted a vision of its goals called the “Truth and Justice Charter.” In it, they have called for the United Nations to address the needs of survivors and their families. PHR urges the international community to heed their call, in order to lay the foundation for a future peace.

Key Recommendations:

To the Syrian Government and Affiliated Forces, and All Parties to the Conflict:

Immediately and unconditionally release all arbitrarily or unlawfully detained health care workers from official and unofficial detention sites.

To the UN Special Envoy for Syria:

Ensure that discussions of human rights and international humanitarian law violations, including arbitrary detention, torture, enforced disappearances, and attacks on health, are prominent within the political process.

To UN Member States:

Coordinate efforts and endorse the Truth and Justice Charter and ensure that survivor-led short- and long-term plans for peace and accountability are the main drivers of decision making.

Introduction

The Syrian conflict has been characterized by a systematic assault on health care facilities by the Syrian government and its Russian allies, with the intent of preventing non-government-controlled areas from receiving medical care. From the earliest days of the conflict, the government arrested, unlawfully detained, and forcibly disappeared health care workers, including nurses, doctors, and medical volunteers, among many others.[2]

Although the government does not acknowledge a forced disappearance, let alone provide information to the family of the disappeared, colleagues, communities, and family members have maintained records of the circumstances of their loved one’s disappearance. The United Nations (UN) estimates that at least 100,000 Syrian civilians have been forcibly disappeared in the past decade[3] and tens of thousands of Syrians have died in detention after being forcibly disappeared.[4]  Health care workers make up an important subset of those forcibly disappeared because, in addition to depriving them of their liberty, the government deprives their communities of the health care they can provide.

This report addresses the detention of health care workers by the Syrian government in the early years of the Syrian uprising. Specifically, it examines outcomes among health care workers – including physicians, pharmacists, nurses, students, and others – who were detained by state security and intelligence forces for providing health care to protesters. The report analyzes 1,685 detentions of 1,644 health care workers (some were detained multiple times) that occurred between 2011 and 2012 and were recorded and maintained by civil society organizations. The records are specific to health care workers who were detained, forcibly disappeared, released, or died while in detention. Through a combination of research, interviews, and descriptive notes from data sets, the report also highlights the experiences of health care workers who were detained.

Any negotiated settlement to the conflict in Syria must address as a central element the issue of Syrians who have been disappeared. Without a clear and sustainable survivor-driven solution for the families of the missing, it is unlikely that any negotiations will result in lasting peace.

A coalition of the families of the Syrian missing has consolidated its demands in the “Truth and Justice Charter,”[5] which lays out policy priorities. Physicians for Human Rights (PHR) recognizes the need for information and closure among the families of the disappeared, including access to the remains of the deceased and the ability to settle legal affairs. It also acknowledges the long-term need for the Syrian government to be held accountable in justice processes for these gross human rights violations. This report will contribute to the discussion of the ongoing grave situation of the many health care workers and others who remain missing in Syria. PHR insists that any negotiated settlement to the conflict in Syria must address as a central element the issue of Syrians who have been disappeared. Without a clear and sustainable survivor-driven solution for the families of the missing, it is unlikely that any negotiations will result in lasting peace.

Background

In March 2011, peaceful protests calling for economic and political reforms broke out across Syria. Unarmed protesters were quickly met with violence and repression by the Syrian government’s security forces, including military units, government-backed militias, and intelligence agencies. As the protest movement grew across the country, the government responded with increasing force and began to systematically target health care workers and others suspected of treating injured protesters.[6] Syrian health care workers willing to treat protesters were unable to provide this care in government-controlled public health facilities without the risk of detention. Therefore, they developed a network of underground “field hospitals” to provide basic trauma care and surgery for civilians injured during protests.[7] These health care workers also created a referral system to help injured protesters avoid detection and arrest. Beginning in March 2011, it was common for state security agents to be present in public – and some private – health facilities, particularly after demonstrations. In all public hospitals, a 24/7 security unit tracked all admissions to emergency departments in order to arrest injured demonstrators and the health care workers treating them. In response, individual health care workers coordinated with private and charity-run health facilities – where security forces were less likely to be present – to facilitate safe access to health care for injured demonstrators. However, if security agents were present in the facility, or if the private hospital manager believed there was a high risk that a security agent would enter, he would usually refuse to accept the transfer.[8]

Syrian health care workers willing to treat protesters were unable to provide this care in government-controlled public health facilities without the risk of detention. Therefore, they developed a network of underground “field hospitals” to provide basic trauma care and surgery for civilians injured during protests.

In retaliation for this medical response that Syrian health care workers provided to the large number of injured protesters, the Syrian government began detaining hundreds of health care personnel working in and supporting the field hospitals and referral network. They were held in facilities where security officials subjected them to horrific conditions and abuses, including torture. Many died, and thousands simply disappeared into the system, their whereabouts unknown to this day. Those whose families had personal connections or wealth often learned of their whereabouts or gained their freedom only after paying hefty bribes.[9] As the country erupted into open conflict in 2012, the government began a coordinated campaign to destroy access to health care by systematically attacking health facilities and health care workers.[10] The Syrian government has long benefited from its political alliance with the Russian Federation, which has provided military support, including Russian airstrikes on medical facilities.[11]

Physicians for Human Rights (PHR) has documented the detention of health care workers in Syria throughout the conflict, in which multiple parties have committed human rights violations and war crimes, including enforced disappearances, torture, sieges, bombing of civilian infrastructure, and widespread and systematic attacks on hospitals and clinics. By December of 2011, the Office of the High Commissioner for Human Rights estimated that 4,000 Syrians had been killed in the context of the uprising. To date, however, the detention and disappearance of health care workers in the initial stages of the conflict, between 2011­­­ and 2012, have not been rigorously examined.

A more detailed assessment of the use of Syria’s detention regime to persecute health care workers is critical to understanding the initial stages of the government’s systematic campaign to undermine access to health care. From March to December 2011, the Syrian government directly controlled most of the country, including all major cities and public health facilities. The government heightened its control of health facilities by increasing the state security and intelligence force presence in them. The military and civil police forces and the four intelligence agencies,[12] or mukhabarat, all monitored emergency room admissions and reported on or detained any patients with injuries that could have occurred at a protest.[13] Security forces also detained any health care provider who failed to report an injured protester prior to providing care. During this period, health care workers throughout Syria became increasingly vulnerable to state violence as Syrian security forces began systematically detaining medical personnel across the country.

The Syrian government detains health care workers because it alleges that the treatment and lifesaving care they provide to its opponents, whom they classify as “terrorists,” constitutes material support for terrorism.[14] Criminalizing health care in this way disregards the protection of care to the sick and wounded in international humanitarian law. Significantly, between March 2011 and July 2012, there was little to no armed opposition, hence no such “justification” for the detention of health care workers. Moreover, President Bashar al-Assad’s repeal of Syria’s emergency law in April 2011, which had for decades given the government the power to arbitrarily detain and arrest perceived opponents, was followed by legislation legalizing peaceful protests.[15] It was not until July 2012 that the government passed the counterterrorism law that codified its unjust practices to criminalize protests and the provision of humanitarian aid, among other activities.[16] In this context, the Syrian government’s actions during this critical first phase of the conflict, prior to the development of an armed opposition, illustrate a clear strategy to intentionally deprive its perceived opponents of access to health care as a means of punishment.

To document this harsh strategy in a sample of health care workers who were detained, PHR examined: 1) characteristics of a large data set of health care workers detained between January 2011 and December 2012; 2) characteristics and outcomes of their detention; and 3) associations between type of health care worker (professional background), reason for detention (medical vs. political), and the detainee’s last known status.

Methodology

The findings in this report are based on secondary analysis of a data set describing 1,685 detentions of Syrian health care workers from 2011 to 2012, in-depth interviews with four members of a medical team operating in Aleppo, and a desk review of open-source documentation of information sources used for creating the timeline and verifying accounts presented in the case study. Physicians for Human Rights’ (PHR) Ethics Review Board (ERB) provided guidance and approved this study based on regulations outlined in Title 45 CFR Part 46, which are used by academic institutional review boards in the United States. All PHR’s research and investigations involving human subjects are conducted in accordance with the Declaration of Helsinki 2000, a statement of ethical principles for medical research involving human subjects, including research on identifiable human material and data.

PHR Data Set

The report is primarily based on a data set containing 1,685 community-generated records of the detention of health care workers from January 2011 to December 2012. Groups of Syrian activists, including health care workers, students, lawyers, and journalists, worked with Local Coordination Committees in different governorates across the country to collect the original data.[17] Those who collected the information followed a system in which as many data points as possible were collected, including: name, profession, data of birth, location of residence, location of arrest or disappearance, and descriptive notes, including other additional information describing the detention event compiled by the activists and added to the database whenever possible. The descriptive notes varied in quality, consistent with the information available at the time the record was produced. The original data was then submitted to civil society organizations that served as central collection sites. The assembled data was subsequently shared with regional and international human rights organizations in order to establish a record of detentions over the last decade. PHR’s research team, composed of experts fluent in Arabic and English and knowledgeable about the Syrian context, compiled the PHR data set (“data set”) by merging, cleaning, and recoding three independent data sets provided to PHR by the Open Society Justice Initiative (OSJI), the Syrian Network for Human Rights (SNHR), and the Violations Documentation Center (VDC).[18]

Cleaning the Data

In order to merge the data sets, the PHR research team systematically reviewed the data and formatted it into a uniform structure across all three data sets. Team members then categorized qualitative data from the descriptive notes section into different variables, including the governorate in which the arbitrary arrest or disappearance occurred,[19] profession, and reason for detention.  The professions of the detainees were grouped into six broad categories: physicians; holders of university-level health science degrees (dentists, pharmacists, and veterinarians); holders of institute-level health science degrees (nurses and technicians); health science students; non-health background; and unknown.[20]

To categorize the reason for a health care worker’s detention, the team systematically searched the descriptive notes about the detention event contained in each data set (where available) for keywords to distinguish between those health care workers detained for their political actions, such as attending a demonstration, and those detained for providing health care to people the government viewed as opponents. In 1,386 detention cases (82 percent), there was insufficient information to determine the reason for detention, so the field was left blank. Some individuals were officially detained, and many others were forcibly disappeared. Forcible disappearance is defined as the secret abduction or imprisonment of a person by a state or political organization, or by a third party with the authorization, support, or acquiescence of a state or political organization, followed by a refusal to acknowledge the person’s fate and whereabouts, with the intent of placing the victim outside the protection of the law.[21]

To distinguish between these two types of detainees, the team searched the notes for references to a legal proceeding. Detainees who received a court sentence or were reportedly held in civilian central prisons were categorized as “officially detained” instead of “forcibly disappeared.” Dates of detention, release, and death were standardized using the month-day-year format. The duration of detention was then calculated by subtracting the date of release or death from the date of detention.[22] Age at detention was calculated by subtracting date of detention from the date of birth.

Ranking and Merging the Sources

The research team ranked the quality of the three data sets according to their comprehensiveness and when they were last updated. The SNHR data set – the largest, most complete, and most recently updated of the three – was ranked highest, followed by the data sets VDC and OSJI provided, in that order. Inconsistencies between the data sets were resolved by deferring to the highest-ranked data set. In cases where entries in the VDC and OSJI data sets matched but differed from the SNHR data set, PHR used the data supported by the majority. When any data set recorded a detainee’s last known status as “released” or “died,” this status was used in place of “forcibly disappeared,” regardless of which data set provided the information. To avoid the duplication of cases, the team de-duplicated records from the merged data set in which the names were the same or substantially similar and matched in three of the following five variables: date of detention, date of release or death, governorate of detention, governorate of origin, and profession.

To obtain the total number of health care workers included in the data set, the team then reviewed all cases with matching names to determine whether the same person was detained multiple times. The team associated multiple detentions with a single person if the names matched, the dates of detention did not overlap, the last known status for every earlier detention was “released,” and there were no conflicting entries for age, gender, profession, or governorate of origin. The team accepted Damascus and Rural Damascus as the same governorate of origin only when reviewing these cases due to shifting administrative boundaries. The team also reviewed the notes sections of each case for any additional identifying information or references to other detentions.[23]

Quantitative Data Analyses

The process of merging, cleaning, and recategorizing the data was completed using Microsoft Excel.[24] The same software was also used to perform and document the de-duplication of cases. The research team then uploaded the PHR data set to Stata, where a Do File and a log were created to document steps in the data analysis.[25] First, all categorical variables were encoded to convert strings (data values that can include letters) into numeric variables. Date of detention and date of release were encoded in Stata and the duration of detention variable was created and calculated in days. String variables were then deleted, and encoded variables were labeled and sorted.

The research team also used Stata to clean the data set by changing the “last known status” for seven cases to “unknown” due to each case having a last known status of “forcibly disappeared” with dates indicating either release or death. Ages below 18 years (two cases) and negative durations of detention (15 cases) were replaced by missing values.

PHR researchers examined the relationships between characteristics of detainees, including their profession, reason for detention, and last known status using STATA. The team examined bivariate associations between detainees’ last known status and their province of detention, profession, and reason for detention in chi-square analyses using an alpha of .05 for statistical significance. Both age and duration of detention were tested for normality. As neither variable was normally distributed, the median was used for reporting. To run logistical regressions and calculate the odds ratios for different outcomes, dummy variables were created for each possible value of the “last known status” and “profession” variables.

Finally, different logistical regressions were run to estimate the odds ratios of each detention outcome using multiple independent variables, including the profession, the reason for detention, and the province of detention for adjustment. The team used an alpha of .05 for statistical significance.

Interviews

In order to elucidate the risks health care workers took, the importance of the services they performed, and the consequences of their detainment by the Syrian government, the PHR team conducted a case study of detentions in the city of Aleppo. The case study relies heavily on interviews a PHR researcher with both country and health expertise conducted between August and October 2021. The PHR researcher interviewed four health care workers who were members of a health team operating in Aleppo in 2012 and who personally experienced detention, had firsthand knowledge of the detention and killing of other health care workers in Aleppo, or both. PHR’s researcher, a native speaker of both Syrian Arabic and English, conducted interviews remotely via Zoom in the language requested by interviewees. The researcher obtained oral informed consent to record the interviews. Primary data was transcribed and analyzed to extract key themes relating to detention of health care workers in Aleppo and the recordings were used to create transcripts of interviews. All personally identifiable information was removed to maintain interviewee confidentiality and safety. Recordings were stored in a secure folder after transcription. After the analysis was completed, the transcripts were stored on a secure PHR server, and the recordings were destroyed as described in the ERB human subjects research protocol. To cross-check dates and corroborate key details, the team consulted a contemporaneous written account of the events covered in the case study.[26] Any inconsistencies were shared with the interviewees for their review.

Desk Review

PHR’s team conducted open-source research to supplement the information from the dataset and the interviews. This desk review focused on the role of health care workers in the development of the Syrian uprising and their detention for providing care to protesters. In addition to PHR’s past interviews with detained health care workers, researchers consulted Google Scholar, Nexis Uni, and ProQuest academic databases, as well as open-source media web searches. Results included articles and reports in English and Arabic published by media outlets, human rights organizations, and UN agency reports from 2011 and later.

Limitations

The findings of this report must be interpreted in the context of eight main limitations. First, due to the Syrian government’s refusal to acknowledge its practice of arbitrary detention and enforced disappearances, it is difficult to independently verify the data sets. Second, because there is often greater awareness of when a person is detained compared to when they are released, the number of health care workers coded as “released” in the data set may be undercounted. Some health care workers may avoid identifying themselves as former detainees to organizations compiling records for multiple reasons, including threats by authorities and the social stigma of having been detained by the state and potentially being subjected to sexual violence or other abuse. For example, upon review of the combined dataset, a PHR researcher with extensive knowledge of the health sector in Aleppo noted that roughly one-tenth of health care workers in Aleppo with the last known status of “forcibly disappeared” had in fact been released (n=10). Third, the Syrian government does not report many of the deaths recorded in the data set. Instead, colleagues and family members often identified the bodies of detained health care workers based on the time when they were discovered at hospitals or appeared in leaked photographs of facilities run by security forces. Because the government provides no information about either detention or death, the number of deaths recorded in the data set is likely an undercount as well and represents the broader limitation of documenting deaths in the Syrian context. Fourth, dates for when health care workers died reflect when family members or colleagues learned of the death. In several cases, an unknown amount of time, ranging from days to years, may have passed between a health care worker’s death and when it was reported. Fifth, female health care workers comprise only 2 percent of the data set. While the overall population of detained health care providers is predominantly male, the social stigma associated with being detained is especially strong for women and likely contributes to an underrepresentation of women within the data set. Sixth, the data sets do not provide information about legal processes related to the release or death of detainees. Seventh, for the case study, the interviewees were asked to recollect traumatic events from a decade before, which may have led to memory bias. While the team sought to use multiple sources of data and cross-check the information provided, it is impossible to independently verify these personal, and often traumatic, accounts, especially concerning the experiences of health care workers who were killed. Lastly, the case study reflects the experiences of a group of health care workers in Aleppo and cannot be used to generalize the experiences of all health care workers in Aleppo or across Syria. Despite these limitations, this study presents a clear glimpse into the Syrian government’s use of detention to penalize health care workers and to reduce the amount of health care services available in the early stages of the Syrian uprising and provides a strong foundation for future study.

Results

Characteristics of Detainees

A total of 2,756 detention cases were merged from the three data sets, resulting in 1,685 unique detention events.[27] Of these, 77 events (4.6 percent) were attributed to 36 people who were detained multiple times.[28] In total, the Physicians for Human Rights (PHR) data set comprises 1,644 health care workers, including 1,607 male health care workers (97.7 percent) and 37 female health care workers (2.3 percent).[29] The research team determined age at detention for 233 cases. The median age was 32 years, with a minimum of 18 and maximum of 76. The team found no correlation between age and last known status.

By profession, the PHR data set includes:

• 614 physicians (110 surgeons, 75 non-surgeon physicians, and 429 physicians whose specialty is unknown)
• 397 health sciences students
• 239 health care workers with degrees from medical universities (111 pharmacists, 85 dentists, and 43 veterinarians)
• 123 health care workers with degrees from health institutes (113 nurses and 10 technicians)
• 183 health care workers with non-health backgrounds
• 88 health care workers whose professions are unknown

The PHR research team determined the governorate of origin for 1,602 cases (95 percent) and the governorate of detention for 774 cases (46 percent).

Characteristics of Detention

Only 31 cases (2 percent) in the PHR data set lack a date of detention. Of the released detainees, 443 cases (94 percent) had dates for both detention and release. The median length of detention was 37 days, with a maximum of 2,778 days (7.6 years). For detainees who were reported to have died while in detention, 58 cases (97 percent) included both date of detention and date of reported death. The median length of time that elapsed between a health care worker’s detention and reported death was 137 days (about 4.5 months), with a maximum of 2,078 days (5.7 years).

The possible classifications for the last known status variables include “released,” “died,” “detained,” “forcibly disappeared,” and “unknown.” The last known status for the majority of detentions in the PHR data set – 1,133 cases (67.5 percent) – was “forcibly disappeared,” meaning the government deprived the detainees of their liberty without a legal proceeding or official recognition that the disappearance had taken place. In fact, there was information suggesting a legal proceeding had occurred, leading to a designation of “officially detained,” in only 15 cases (1 percent). Of the remaining 31.5 percent of detentions, the team found 470 cases (28 percent) where a health care worker was released after being detained, and 60 cases where people (3.5 percent) died in detention. Of those who died, 15 (25 percent) were physicians, 18 (30 percent) were health care workers from non-health backgrounds, and 13 (22 percent) were health sciences students. Many detainees reportedly died during torture, were intentionally killed, or died from lack of medical care.[30] In at least one case, the notes indicated that the Syrian government reported the cause of death for a detainee as suicide, but a fellow detainee later reported that the person had been tortured to death. Detention events with a last known status of “unknown” (0.4 percent) were not included in any analysis using last known status.

The PHR research team determined the reason for detention in 299 cases (18 percent). In 193 cases (64.5 percent), health care workers were detained for providing health care, including by working in a field hospital, transferring patients to medical facilities, offering medical treatment to protesters, or carrying medical equipment. In the remaining 106 cases (35.5 percent), the health care workers were detained due to their involvement in political activities, including participating in protests, engaging in peaceful acts of civil disobedience, and joining opposition parties. Of the health care workers who were detained for providing health care, 75 percent were forcibly disappeared, 10 percent died in detention, and only 14 percent were released. In comparison, among the health care workers detained for their political activities, only 31 percent were forcibly disappeared, 4 percent died, and the majority (63 percent) were released.

Associations Between Profession, Reason for Detention, and Last Known Status^[31]

In bivariate analyses, there was a statistically significant correlation between reason for detention and last known status (P <.001). Overall, health care workers who were detained for providing medical care had 91 percent lower odds of being released than those who were detained for political reasons. These individuals were also 550 percent more likely to be forcibly disappeared compared to health care workers detained for political reasons. Within the same governorate and professional group, detainees who had provided medical care were 400 percent (P = .015) more likely to die in detention than detainees who were detained for political activities.

There was also a statistically significant correlation between detained health care workers’ professional group and their last known status (P < .001). The findings were particularly pronounced when comparing physicians and non-physicians. The odds that a physician would be released were 143 percent greater compared to a non-physician. Physicians were also 52 percent less likely to be forcibly disappeared and 48 percent less likely to die in detention compared to non-physicians (P = .03).

Each of the other four professional health care worker groups – detainees with university-level health science degrees (dentists, pharmacists, and veterinarians), institute-level health science degrees (nurses and technicians), health sciences students, and those with a non-health background – had higher odds of being forcibly disappeared and lower odds of being released compared to their physician peers. For enforced disappearance, dentists, pharmacists, and veterinarians had 66 percent higher odds (P = .001), nurses and technicians had 166 percent higher odds, health sciences students had 69 percent higher odds, and people with non-health backgrounds had 229 percent higher odds of being forcibly disappeared compared to physicians. These same groups had between 41 and 90 percent lower odds of being released compared to physicians (P ≤ .001). People with non-health backgrounds were also 353 percent more likely to die in detention than physician detainees. It is important to note, however, that most physicians in the PHR data set experienced poor outcomes. Only 255 physicians (40 percent) were released, while 359 (56 percent) were forcibly disappeared and 15 (2 percent) died in detention.

Discussion of Findings

Physicians for Human Rights’ (PHR) analysis yielded two main findings from the data on detention during this period: health care workers detained for providing medical care experienced worse outcomes than health care workers detained for political reasons, and among detained health care workers, physicians overall experienced better outcomes than non-physicians.

Reason for Detention and Outcomes: Health Care vs. Political Activity

As only 18 percent of cases in the data set had notes indicating the reason for detention, any interpretations of the differences in outcomes between medical and political detainees are tentative. With that caveat, the finding that health care workers who were detained because they had provided health care experienced worse outcomes then those detained for political reasons is striking. This finding could be interpreted as suggesting that government officials running the detention and interrogation system regarded providing medical aid to injured protesters as a more serious crime than participating in protests. This may be a result of the government assuming that health care workers detained for providing aid may have helped multiple protesters, thereby multiplying the perceived crime. Regardless of the reason, this finding reinforces the idea that the Syrian government decided to criminalize and harshly punish the provision of health care to protesters.

The finding that health care workers detained for providing health care had worse outcomes may also help explain the disparity in outcomes between physicians and non-physicians. Due to a relative lack of skills and experience, health sciences students and health care workers with non-health backgrounds may have been more active in providing basic first aid in the field compared to trained physicians. If these non-physicians were caught with medical supplies or while treating a protester at the scene of a protest, they would have had little room for disputing an accusation of providing health care. Physicians, on the other hand, would have greater deniability or could claim ignorance if detained on suspicion of treating protesters in a hospital. This may have influenced how interrogators and jailers perceived the severity of the crime, which could have affected both the treatment of health care workers in detention as well as the size of the bribes they were able to pay to secure their release. This would consequently help explain why physicians, with their greater economic means, appear to have been released more frequently than non-physicians.

Only three health care workers in the data set experienced detention more than twice, two of whom were detained four times. One of them was a dentist, and the other two were physicians. None of them were ever detained for providing health care, although the reason for detention was not known in every case. These three health care workers may have benefited from some unknown factor that allowed them to repeatedly exit the detention system alive. However, it is also possible that because none of them were detained for providing health care, and two were physicians who may have benefited from having wider professional networks and more economic resources, these health care workers were among the groups most likely to avoid poor outcomes.  

Class and Status

Given that physicians represent the largest group of health care workers who were detained in our data set, the finding that physicians experienced better outcomes relative to other health care workers may seem paradoxical. These better outcomes, however, may be explained in part by the cultural and economic capital Syrian physicians enjoyed, particularly in the earliest years of the conflict. Specifically, their status as physicians may have provided access to a larger network of connections and to monetary resources that may have allowed them to navigate the detention process more successfully than non-physician detainees.[32]

When a person has been detained in Syria, there is strong evidence that social connections or “wasta” play a crucial role in the family learning the location of the detention site, the security service detaining their family member, and the alleged reason for detention.[33] Physicians in Syria, because of their role in the community, may have enjoyed larger professional networks that are capable of advocating on their behalf than non-physicians. These connections may have allowed family members and colleagues to locate where the detainee was in custody and communicate with the branch of the responsible security apparatus. Detainees whose families and colleagues lacked the necessary connections to access this information may have been at higher risk of disappearing into the Syrian government’s secretive detention system.

Once a detainee is located, the process of negotiating that person’s release may require a substantial amount of money. Systematic corruption within the detention system in Syria has created a significant source of revenue for government officials in positions to extort families and solicit bribes in exchange for securing the release of detainees.[34] Former detainees have reported that bribes were necessary for release and at times critical to avoiding death in detention. Physicians have historically received the highest salaries of all health care workers and may come from families with more economic resources.[35] Consequently, the families of physician detainees included in the PHR data set may have been better able to afford the price of survival.

Although the data set does not include information about detainees’ experience of cruel and inhuman conditions or torture, there is ample information that torture is common in Syrian detention facilities.[36] For example, the UN Commission of inquiry on Syria found that between March 2011 and November 2015, the Syrian government’s detainees were beaten and tortured to death or had inhuman living conditions inflicted on them, including serious over-crowding, lack of food, unclean drinking water, and lack of medical care.[37] This is also consistent with PHR’s previous research on the torture of health care workers detained by the government.[38]

Post-2014 Release Trend

Another important observation from the data set is that only six (1.3 percent) of the 470 cases of release occurred after 2014. Many reasons may account for this, including the mass forced displacement of millions of Syrians, both internally and abroad, Syria’s economic decline, and a possible shifting of government policy away from release of those detained for providing health services. The economic crisis in particular may have decreased the ability of many previously well-resourced families to afford bribes and may have disrupted personal networks. The punishment for providing health care may also have increased in severity as peaceful protests gradually gave way to armed opposition.

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“Protesters who were injured by the security and secret police could have been detained, tortured, or killed, had they sought normal medical care.”

Dr. Karim, a surgeon and member of the Noor al-Hayat medical team[39] 

Aleppo’s Noor al-Hayat Medical Team

Killed for Treating Demonstrators

In the early days of the Syrian uprising, when the government of President Bashar al-Assad was violently suppressing peaceful demonstrations, 13 health care workers in Aleppo formed the Noor al-Hayat medical team to provide care to injured protesters. The group included two doctors, three dentists, a pharmacist, five medical students, and two non-health sciences university students. Before the uprising, each of them had enjoyed a peaceful life and a promising future. Within a year of Noor al-Hayat forming, half of the members had been detained and tortured, and four of them had lost their lives.

How the Noor al-Hayat Team Was Established

Throughout 2011 and 2012, Syrian security forces inflicted frequent and serious injuries on protesters peacefully demonstrating against the government. Wounded protesters were branded as criminals and “enemies of the state” and were threatened with detention and death if they attempted to seek care at public hospitals. “Security agents would come to the hospital, questioning and interrogating the injured,” said Dr. Bassam, a dentist. Because of these risks, in January of 2012, Dr. Mansur, a pulmonologist, established the Noor al-Hayat team to provide lifesaving medical care to anyone injured during peaceful demonstrations in the city of Aleppo. The team provided first aid at protest sites, performed emergency medical procedures in field settings – including private homes and other structures – and coordinated admissions to private hospitals when demonstrators required surgery. Since the Syrian government did not maintain a constant presence in all of Aleppo’s private hospitals, protesters seeking care in those hospitals were at lower risk of being found by security forces and detained.

How the Noor al-Hayat Team Carried Out its Work

When a demonstration began, the Noor al-Hayat team deployed to the area, ready to provide care. As protesters were injured, team members administered basic first aid using pre-prepared medical kits. Each kit contained several oropharyngeal tubes (used to maintain an open airway), a compression bandage, two tetanus injections, intravenous fluids (used to treat blood loss), and painkillers. The medical students were the team’s frontline health care providers, who attended demonstrations to treat emergency cases and identify victims with serious injuries. Dr. Karim, a surgeon, explained his role: “I was responsible for the field management, meaning I would refer cases to the appropriate hospital and reach an agreement with other doctors to treat the injured protesters.”

Treatment in any hospital – even a private one – was never completely safe, but other options were limited. Patients injured during protests would claim to have been attacked by “terrorist groups” to avoid being labeled as protesters and detained. However, some families decided it was too risky and preferred treatment at a field medical point – despite knowing they had minimal to no equipment and very low hygienic standards – to avoid the risk of their family member being detained at a hospital. “I remember a young, injured protester whose situation was critical,” Dr. Karim recalled. “His family refused [to admit him to a hospital], saying ‘The regime knows he is one of the protesters. They will kill him.’” Dr. Karim added that when a patient had surgery, the team would try to get him discharged as quickly as possible because “the police would come to check and see where he came from and how he was injured.” At one point, Dr. Karim recalled how security agents at a hospital tried to arrest a 16-year-old boy with a spinal cord injury. Dr. Karim and his wife joined a sit-in at the hospital to prevent the injured boy’s arrest. While the boy was ultimately not detained, Dr. Karim partially credited the success to someone leveraging their social connections to obtain “the help of someone with a critical role in Parliament.”

Detention, Torture, and Death

Dr. Mansur was an outspoken critic of the Syrian government. He posted on social media using his own name and actively encouraged the protest movement in Aleppo. He was detained by the government multiple times and died five months into his third detention in June 2012. During that time, he sent several messages to his family through detainees who had been released. He told his family he was being severely tortured. He asked them to pay bribes to set him free. When his family finally received his body, it was unidentifiable. He had lost more than 100 lbs in detention and his brother, a dentist, could only identify Dr. Mansur by a tooth that he had replaced. 

On June 17, 2012, three student members of Noor al-Hayat – Abdullah, Hassan, and Ibrahim – were returning home at 1:00 a.m. after helping treat injured demonstrators. They were carrying a medical kit with them in the truck they rode in, identifying them as health care workers. Samir, a fellow Noor al-Hayat medical student member, recalled that they had planned to meet at the al-Razi hospital for training that evening. Samir last spoke to the group around 10:00 p.m., when they told him that they were attending to another patient and would not make it to the hospital that night. The next morning, Hassan’s family called the team and told them that Hassan never arrived home.  

The team later learned that Abdullah had called a friend and told him that they were being stopped at a security checkpoint in the al-Hamdaniya neighborhood. Abdullah’s friend said that he immediately went to the area and saw the three students in the back of a security vehicle. When Hassan’s family realized that he was missing, they called his cell phone repeatedly. A person identifying himself as a government official answered Hassan’s phone and told them that their son had been detained. Samir remembers that they were air force security branch officers. The officers told Hassan’s parents, “You did not know [how] to educate your child, we will do that for you.” Hassan’s parents feared the worst because the accusation against him was of providing medical services. Immediately after the three students were detained, the remaining Noor al-Hayat members halted their work, removed all the medical equipment from the field hospitals, and avoided returning to their homes.

Samir recalled that six days after the students were initially detained, Ibrahim’s family received a call from their son’s phone. An official on the other end of the line directed them to a car that contained the burnt bodies of the students. Samir, who had worked in forensic medicine, accompanied Hassan’s brother to identify his body. “There were signs of beating and torture by flogging on his back,” Samir recalled. “We could identify Hassan because his body was not completely burned…. The worst part was that he was handcuffed and shackled so tight that you could see bone. He had a gunshot wound behind the left ear.”

Abdullah’s father and Ibrahim’s brother tried to identify the bodies of their loved ones, but their injuries had left them unrecognizable. Eventually, Ibrahim was identified by one of his shoes and Abdullah by his belt buckle. Later, graphic photos and videos appeared on the internet showing that Abdullah, Hassan, and Ibrahim had been burned with their hands tied behind their backs.[40] The brutal killing of the Noor al-Hayat team fueled a surge of protests in Aleppo.

“There were signs of beating and torture by flogging on his back…. We could identify Hassan because his body was not completely burned.”

Samir

Tortured but Released: Jamal and Rahim’s Story

After the burnt corpses of the three student volunteers were found, the remaining members of the Noor al-Hayat team resumed their work. However, the risks associated with their efforts had not decreased. Rahim described how he and his friend Jamal were detained after security forces caught them in possession of medical equipment. It was in August 2012, during Ramadan: “We had gone to get some food for Iftar [to break the fast], as well as to get some medical equipment … near the al-Bassel roundabout in New Aleppo,” Rahim recalled. Three agents from the nearby Military Security Directorate branch stopped them after their car had been reported for suspicious activity. When the security agents discovered the medical kit, they brought the students to the military security branch, located next to the roundabout.

At the branch office, Jamal and Rahim tried to claim they were volunteers with a government-approved organization, but the military security officers did not believe them. “I said goodbye to Jamal, and I thought we were definitely dead,” remembered Rahim. “We had a similar kit to the one Abdullah, Hassan, and Ibrahim had, and it is obvious we [were] from the same team.”

The cells were small, crowded rooms, with no furniture or mattresses. Rahim explained that they put detainees in a group cell measuring 5 x 6 meters (16.4 x 19.7 feet) with “40 or 50 people. I mean, if you wanted to lay down, you could not lay down on your back, you would have to be on your side and you [could] not extend your legs.” There were no toilets in the cells, and detainees were only allowed to use the bathroom twice every 24 hours. “They would allow you to use the toilet only until they counted to 10.”

“I said goodbye to Jamal, and I thought we were definitely dead.”

Rahim

Rahim recounted that, during interrogation, he was verbally abused and tortured. He described how his interrogators blindfolded and bound him, then hit him from all sides. He remembers them saying, “So, you’re treating the terrorists?” They tried to scare Rahim and Jamal by telling them that the other had pleaded guilty and told everything. “Me and Jamal were agreed that if we were caught, never to tell the truth whatever [happened], so we knew they were lying.”

Jamal and Rahim were held for 17 days. Neither believed that they would get out alive, thinking instead that they would be tortured to death. However, on the outside, Jamal’s relatives were using their connections to find out what had happened to the men and negotiate their release. In the end, Jamal’s family sold a house to afford the massive bribe that government officials demanded in exchange for facilitating the release of Jamal and Rahim. When the pair left the detention center, the security officials who had detained them told them to deny that they had ever been detained and never to discuss what was done to them.

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Supporting Information from Previous PHR Documentation

The findings from PHR’s dataset regarding Syrian authorities’ criminalization of medical care are consistent with PHR’s longstanding research on the Syrian government’s attacks on health care facilities and providers.

In previous interviews that PHR conducted with health care workers who were detained between 2011 and 2012, interviewees recounted Syrian authorities telling them that they were detained for being doctors or for providing health care.[41] Interrogators accused many of the interviewees who worked in or helped establish field hospitals of providing medical treatment to “terrorists,” and/or of working to overthrow the Syrian government.

In October 2011, Air Force Intelligence agents arrested Dr. Ahmad, a surgeon, while he was operating on a patient with a thigh injury in Hama governorate. Dr. Ahmad subsequently learned during his interrogation that the authorities suspected the patient of being a “terrorist.” Dr. Ahmad’s act of providing medical care was the only justification given for his detainment. “My only crime was that I was a doctor,” he said.

Dr. Hadi, a pediatrician in Daraa, described being detained for possessing medical supplies at a checkpoint. “On August 9, 2012, in the late afternoon, I was stopped at a military checkpoint on the main highway between Daraa and Damascus,” Hadi recalled. “It was a 9th Armored Division checkpoint…. On that day, I was with a driver, and we were transporting a quantity of medical supplies – saline, antibiotics, gauze, medical plaster, etc. – to a field hospital in Daraa.” That same evening, an interrogator at the base accused Dr. Hadi of intending to equip a field hospital that treated protesters. Syrian authorities detained him without legal justification for nearly six months, during which he was repeatedly interrogated and tortured before he was finally released after paying a bribe to a judge.

In August 2011, Dr. Youssef was arrested as he was treating a patient in a hospital in the Qalamoun region, north of Rural Damascus governorate. Security forces took him to the al-Khatib State Security Branch, where interrogators repeatedly asked him about the medical point network he had helped to establish and demanded he identify the network’s members. His interrogators told him that they detained him for supporting “terrorists” and working against the regime.

Legal and Policy Analysis

Brief Legal Overview

While an in-depth legal analysis lies outside the scope of this report, this section addresses the overall legal implications of the data presented in this project and germane policy initiatives.

The permanent, nation-wide state of emergency declared in Syria in 1963 resulted in the emergence of a parallel judicial system. In this system, people perceived as threatening by the Syrian government were sent to both official and unofficial detention sites after trials in “exceptional courts,” including military courts and the Supreme State Security Court.[42] Some observers praised the Syrian government for suspending the emergency law on April 21, 2011.[43] Physicians for Human Rights’ (PHR) analysis demonstrates that this praise was misplaced. Significantly, in the months after the lifting of the emergency law, and before the December 1, 2011 United Nations (UN) determination that civil war was occurring in Syria, the government subjected health care workers,[44] among many thousands of others, to arbitrary detention and enforced disappearances in violation of its obligations under domestic law, international treaties, and customary international law. PHR’s qualitative research, including “My Only Crime Was That I Was a Doctor” and multiple other credible sources, suggest a high likelihood that torture and extrajudicial killing of health care workers occurred while they were in detention.[45] These practices were legitimized the following year when Syria’s counterterrorism laws were signed into legislation on July 2, 2012.[46] The definition of terrorism in these laws is so broad as to include any opposition to the Syrian government, including the provision of first aid or other medical care to individuals the government deems its opponents.[47] These laws have effectively recreated the exceptional court system by establishing a Counterterrorism Court.

Relevant Legal Framework

This report shows that health care workers were arbitrarily detained and forcibly disappeared during peaceful protests in the first eight months of the conflict, prior to the UN’s recognition of civil war in Syria. Its analysis finds poorer outcomes for health care workers charged with providing medical care than those engaged in political protest, which is corroborated by the interrogator’s statements reported in the case study and in earlier PHR interviews with health care workers across Syria. PHR finds that the Syrian government targeted health care workers with detention, abuse, and torture for providing medical assistance. The allegations merit a robust investigation of multiple violations of domestic laws, human rights law, and international humanitarian law. 

Domestic Rule of Law Provisions

The Syrian Constitution (2012) provides theoretical protections against arbitrary detention as well as torture. Articles 51-53 of the Constitution articulate rule of law principles, including the presumption of innocence in trials, the right to counsel, the right to fair trial, the prohibition of torture and cruel treatment, and the prohibition of false imprisonment.[48] The Syrian Penal Code and the Code of Criminal Procedures provide for similar procedural protections.[49]

International Humanitarian Law (IHL)

This report focuses on the arbitrary detention and abuse of health care workers by the Syrian government in the first phase of the popular uprising. There is no consensus on when the non-international armed conflict in Syria – required for the application of international humanitarian law (IHL) – was established. For the purpose of this legal analysis, after the UN determination of civil war in Syria in December 2011, the conflict can be characterized as primarily a non-international armed conflict in which obligations arise under both international treaty and customary law.[50] The Geneva Conventions of 1949, which Syria ratified in 1953, are at the heart of IHL. They contain provisions related to protecting civilians, regulating detention, and safeguarding medical personnel. Common Article 3 of the Geneva Conventions applies to all parties to the conflict in Syria and contains specific stipulations on the equal and humane treatment of persons taking no active part in hostilities, including the passing of sentences and the carrying out of executions without previous judgment by a “regularly constituted court.”[51] In addition to the IHL obligations arising under treaty law, the Syrian government and other parties to the conflict in Syria are bound by customary international law (CIL) in conflicts, which provides protections against the arbitrary deprivation of liberty, enforced disappearances, torture and other cruel and inhuman punishment, and murder.[52] Significantly, CIL protects medical personnel engaged exclusively in medical duties, and prohibits the punishment of a person for performing medical duties as demanded by medical ethics.[53] By attacking medical workers in this context, the Syrian government has committed war crimes.

International Human Rights Law

Syria is party to multiple international treaties prohibiting arbitrary detention, abuse, and torture. It has ratified the International Covenant on Civil and Political Rights, which provides in relevant part the prohibition of torture (Art. 7) and arbitrary arrest or detention (Art. 9); the humane treatment of detainees (Art. 10); and the provision of fair trials (Art. 14).[54] The right to free speech (Art. 19) protects the choices of health care workers to participate in protests as well as to provide care to injured protesters. As discussed above, there is high likelihood that health care workers subjected to arbitrary detention and enforced disappearance have also experienced torture. Syria has ratified the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment that requires States parties to actively prevent acts of torture in territories under their jurisdiction, allowing for no derogation under any circumstances, including in a state of war, internal instability, or public emergency.[55]

Syria has also ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR), which provides in Article 12 the right to physical and mental health.[56] By systematically detaining health care workers, the Syrian government has not only decreased the census of available providers, it has also created a chilling effect on the provision of health care, no matter how basic, to unarmed protesters.

The UN defines arbitrary detention as depriving persons of their liberty in a way characterized by “elements of inappropriateness, injustice, lack of predictability and due process of law,”[57] which applies before, during, and after trial, as well as in the absence of a trial (administrative detention). As with arbitrary detention, enforced disappearances involve depriving a person of liberty against their will and without due process. An enforced disappearance has the added element of state involvement – either through direct action or by acquiescence – coupled with the state’s concealment of the fate of the disappeared person or refusal to acknowledge that the enforced disappearance occurred.[58]

In 2015, the United Nations, “on the basis of the general consensus of contemporary thought,” adopted the Standard Minimum Rules for the Treatment of Prisoners (the “Mandela Rules”). These rules establish good practices for the treatment of prisoners and the management of penal institutions.[59] Although they are not legally binding, they lay out international agreement on good principles and practice for the treatment of prisoners, and as such can be persuasive. The Mandela Rules provide that prison administrations must allow detainee contact with families, access to medical care, and sufficient water and food, in addition to preventing torture, ill-treatment, and sexual violence.[60]

Although Syria is not a party to the Rome Statute of the International Criminal Court, a referral to the court is possible through a range of mechanisms. Article 7 of the Rome Statute provides that when committed as part of “a widespread and systematic attack directed against any civilian population,” imprisonment or other deprivation of physical liberty, torture, and enforced disappearance may be considered crimes against humanity.[61]

Recognition of Truth as a Right

Critically for this report, the right to the truth relating to enforced disappearances or missing persons is recognized in a number of international legal instruments. Article 32 of Protocol I to the Geneva Conventions establishes “the right of families to know the fate of their [disappeared] relative.”[62] Although Syria has not signed the 2006 International Convention for the Protection of All Persons from Enforced Disappearance, it has ratified the ICESCR. The Economic and Social Council treaty body charged with monitoring compliance of signatories to the ICESCR has reaffirmed the “inalienable right to know the truth” regarding human rights violations, including enforced disappearances, and the truth regarding the fate and whereabouts of the disappeared persons, noting it is an absolute right, not subject to any limitation or derogation.[63] The UN Working Group on Enforced or Involuntary Disappearances has further elaborated on this principle by finding a right to know about the progress and results of an investigation, the circumstances of the disappearances, and the identity of the perpetrators.[64]

The Syrian government has carried out a policy of forcibly disappearing health care workers for the past decade, in violation of its international legal obligations, including under international humanitarian law, international human rights law, and its own domestic human rights protections. Enforced disappearances punish critics of the government but also create uncertainty and fear in a population as a way to discourage further opposition. As detailed above, the system into which so many Syrians have disappeared is subject to corruption and misinformation. Syria’s domestic and international legal obligations to the families of the missing and to detainees themselves must be addressed.

Policy Approach: Humanitarian Response and Justice

The UN Commission of Inquiry on Syria, noting that forced disappearances directly harm both detainees and families, has observed that the harms “represent a national trauma that will affect Syrian society for decades to come.”[65] Research has demonstrated that the disappearance and death in detention of significant others is associated with an increased risk of a range of serious psychological disorders.[66] Representatives of the families of detainees killed in detention or still missing have spoken publicly about the pain they have experienced. As the sister of a detainee who died in detention explained, “Neither I nor my mother can regain our previous lives, as long as the one who killed him still kills others and does not feel the guilt for what he did, nor how he injured and destroyed our lives.”[67] The mother of a detainee who was forcibly disappeared and is still missing explained that each of the missing “is a human soul with a full life to live. We’re not talking about numbers. We’re talking about humans, about our sons, about our loved ones.”[68]

Two main initiatives discussed below to address survivors’ needs – for information, closure, services, support, and ultimately for justice – include the Truth and Justice Charter movement and legal approaches using the principle of universal jurisdiction.

Survivor-led Justice Initiatives

In February 2021, a coalition of five Syrian organizations drafted a statement of goals called the “Truth and Justice Charter.”[69] These organizations represent survivors, their families, and family members of the missing who were subjected to arbitrary detention, enforced disappearance, torture, and serious ill-treatment in detention.[70] The Charter states,

“We differentiate between short-term justice and long-term justice. In the short term, there are immediate measures that must be taken to put a halt to ongoing violations and alleviate the suffering of survivors, victims, and their families. In the medium- to longer-term, we have additional demands to ensure comprehensive justice and non-repetition of the crimes we have suffered and continue to suffer from.”

The organizations have called for the UN to create a mechanism to follow a “strictly humanitarian approach” to address immediate needs.[71] However, it would also liaise with UN entities collecting information for future justice processes, including the Commission of Inquiry and the International, Impartial and Independent Mechanism to support their respective mandates.

Universal Jurisdiction Cases

Lawyers seeking justice for victims of grave crimes in Syria have pursued cases against perpetrators residing in the eight countries that have adopted “universal jurisdiction” legislation.[72] Universal jurisdiction allows a national court to prosecute individuals for serious crimes against international law — such as crimes against humanity, war crimes, genocide, and torture – on the principle that these crimes harm the international community itself, including the country in which the case has been filed. While universal jurisdiction offers a path forward for those seeking accountability for survivors and families of the missing, significant funding and capacity challenges remain.

Conclusion

Physicians for Human Rights’ (PHR) analysis suggests that from the earliest days of the uprising, even before the conflict began, the Syrian government embarked on a systematic and widespread campaign to detain anyone who provided medical assistance to protesters. In most cases, these health care workers were not lawfully arrested, charged, or given a fair trial. Instead, they were taken from their homes and places of work, seized while treating patients or traveling through checkpoints, and held in detention facilities where torture was rampant; many died or have not been heard from again. The pervasive illegality and opacity of the detention system appears to have acted as a breeding ground for corruption. Detainees who could leverage social connections and afford to bribe officials, as confirmed through numerous interviews, could secure their release. Those without social and financial capital faced intractable barriers, walls that were raised even higher if they were accused of providing health care. 

The harm detailed in this report extends far beyond 2012, and even beyond the detainees themselves. What this report does not adequately show are the physical, mental, emotional, and social challenges that detainees can face even if they are released, especially after surviving torture, sexual violence, and other horrific abuse; nor does it cover the harm inflicted upon the families of the missing, who, every day, endure the pain of not knowing if their loved ones are being tortured in a detention site or lying in a mass grave.   

A decade after the Syrian government began intensifying its practice of forcibly disappearing civilians, including health care workers, the conflict in Syria has entered a tenuous period of negotiation, with the potential for a fragile peace. However, justice and accountability remain elusive. As fighting continues unabated in some areas, the government of Syria, under the auspices of the Astana process aimed at achieving a ceasefire and agreement on humanitarian issues,[73] has entered into piecemeal negotiations to reclaim territory. In addition, some countries are encouraging the return of Syrians who fled their homeland. The Russian Federation, which has actively provided military support to the government of Syria since 2015, serves as a guarantor of its peace negotiations. PHR urges that the voices of the missing persons’ families be heard in the context of any negotiations going forward. While the nature of enforced disappearance makes it impossible to appreciate the full scale of violation and trauma, the UN has estimated that at least 100,000 people have been arbitrarily detained or forcibly disappeared. It is imperative for families to learn the truth about their loved ones’ disappearance, and, where possible, to retrieve their bodies. In addition to the need for truth, there is a longer-term need for justice and for accountability for the mass forced disappearance of opponents to the regime and those who provided care to the sick and wounded according to their ethical and moral imperatives. Health care workers are vital to the public health of their communities, but respect for the lives of all detainees and the need for truth and justice for the survivors must be recognized in both the short and the long term.

Recommendations

The status of detainees in Syria has been deemed fundamental to any political negotiation between the parties to the conflict, but with limited results.[74] The Syrian government is now seeking to normalize diplomatic relations with the international community, particularly its neighboring states. This creates a critical opportunity for the international community to explore new methods to pressure all parties to the conflict to negotiate for the release of detainees and to demand transparency from the Syrian government about the status of those who have died in detention. Physicians for Human Rights makes the following recommendations:

To the Syrian Government and Affiliated Forces, and All Parties to the Conflict:

• Immediately and unconditionally release all arbitrarily or unlawfully detained individuals from official and unofficial detention sites;
• When facilitating the release of all arbitrarily detained people, special attention should be given to the most vulnerable, including children, women, the elderly, and the disabled;
• In response to the Truth and Justice Charter, create a national-level channel for Syrians to report and seek information about their missing and disappeared loved ones;
• Take immediate and systemic measures to prevent the torture and ill-treatment of detainees and ensure that allegations of abuse are investigated, and abusers held accountable;
• Disclose the locations of all official and unofficial detention sites and provide comprehensive lists of all those held in those sites;
• Share information with families on the location and status of detained and abducted relatives. When applicable, notify families of the circumstances of death and the location of burial sites;
• Establish and abide by a timetable for the release of detainees and information about the missing;
• Grant impartial and independent entities access to all prisons and detention sites, regardless of the entities’ official status;
• Improve detention conditions in compliance with international standards, including through ensuring detainee contact with families, access to medical care, and sufficient water and food, as well as preventing torture, ill-treatment, and sexual violence. This is especially critical in the context of the COVID-19 pandemic; and
• Respect health services and protect medical personnel, patients, facilities, and transport from attack or interference.

To the Russian Federation: (As the main supporter of the Syrian government and a party to the conflict in Syria)

• Use influence to press the Syrian government to implement the above-listed recommendations, focusing on the unconditional release of those arbitrarily detained, disclosing information to families on the fate and whereabouts of detained relatives, and granting access by international monitors to detention sites; and
• Support UN Security Council (UNSC) measures to accelerate the release of the arbitrarily detained, including medical personnel, in accordance with resolutions 2139 and 2254.

To the United Nations Security Council:

• Address non-implementation of prior UN Security Council resolutions by adopting a stand-alone resolution on the situation of detainees and missing persons, setting out in detail the steps that the government of Syria is required to take under international law;
• Enforce accountability by referring the situation in Syria to the Prosecutor of the International Criminal Court;
• Adopt targeted sanctions against persons, agencies, and groups credibly suspected of being responsible for or complicit in conduct leading to arbitrary arrests, custodial deaths, torture, and enforced disappearances;
• Encourage all parties to the conflict to abide by UNSC resolutions 2139, 2254, 2268, and 2474 and draw specific attention to the targeting of medical personnel; and
• Continue to reinforce the work of the International, Impartial and Independent Mechanism to Assist in the Investigation and Prosecution of Persons Responsible for the Most Serious Crimes under International Law committed in the Syrian Arab Republic since March 2011, and the Independent International Commission of Inquiry on the Syrian Arab Republic, which are charged respectively with collecting and storing information about and investigating alleged violations of international human rights law.

To the UN Special Envoy for Syria:

• Ensure that discussions of human rights and international humanitarian law violations, including arbitrary detention, enforced disappearances, torture, extrajudicial killings, and attacks on health, are prominent within the political process; and
• Re-insert the issue of detainees, abductees, and the missing into the framework of the Geneva peace process and push the Astana Guarantors to widen the scope of the Working Group on Detainees and Abductees beyond its current focus on low-level one-to-one prisoner exchange and into a scalable release of civilian prisoners.

To UN Member States:

• Coordinate efforts and endorse the Truth and Justice Charter and ensure that survivor-led short- and long-term plans for peace and accountability are the main driver of decision making;  
• Support the creation of an independent and impartial mechanism to seek the truth about the fate and whereabouts of missing and forcibly disappeared people in Syria; and
• Exercise international and domestic law, including universal jurisdiction principles, to investigate and prosecute Syrian military and civilian officials responsible for carrying out war crimes and crimes against humanity against detainees in Syria. Ensure cooperation among states, including sharing of evidence bilaterally, where possible, with national prosecutors who are pursuing these cases in domestic courts.

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Acknowledgments

This report was written by Physicians for Human Rights (PHR) staff members Houssam al-Nahhas, MD, MPH, MENA researcher (November 2020 – August 2021); Andrew Moran, Syria research and investigations associate; 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. Hala Mkhallalati, MSc, research associate, Saw Swee Hock School of Public Health, National University of Singapore, contributed to the writing and conducted interviews. Joseph Leone, former research and investigations fellow, contributed to the project concept memo. MENA interns Youssef Aziz, Sarah Kebaish, Samantha Scheer, and an anonymous MENA intern provided research assistance.

PHR leadership and staff contributed to the writing and editing of this report, including Michele Heisler, MD, MPA, medical director; Donna McKay, MA, executive director; Karen Naimer, JD, LLM, MA, director of programs; Michael Payne, deputy director of advocacy; and Susannah Sirkin, MEd, director of policy and senior advisor.

The report benefited from review by PHR Board Member Emeritus Robert S. Lawrence, MD; Mohammad Darwish, MD, MPH, associate faculty at the Center for Humanitarian Health, Department of International Health at John Hopkins Bloomberg School of Public Health; Mohamad Katoub, MD, research fellow, Syria Impacts Study, University of California, Berkeley, School of Public Health; and Steve Kostas, JD, PhD, senior legal officer, Open Society Justice Initiative. It was reviewed, edited, and prepared for publication by Claudia Rader, MS, senior communications manager, with assistance from Abigail Daly, communications intern. Hannah Dunphy, MA, digital communications manager, prepared the digital presentation.

PHR would like to thank the Open Society Justice Initiative, the Syrian Network for Human Rights, and the Violations Documentation Center for the data they shared. PHR is grateful to Ali Barazi and his associates for translation services. PHR is especially indebted to the former members of the Noor al-Hayat Medical Team who agreed to be interviewed.

This report is supported in part by funding from the German Federal Foreign Office’s Institute für Auslandsbeziehungen, through the zivik Funding Programme. 

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Endnotes

[1] These concessions included the repeal of a 48-year-old state of emergency law that the government had used for decades to arbitrarily detain perceived opponents.

[2] United Nations Human Rights Council (UNHRC), Independent International Commission of Inquiry (CoI) on Syria, “Assault on medical care in Syria” (A/HRC/24/CRP.2), September 17, 2013.

[3] United Nations Security Council, “Security Council Failing Thousands of People Detained, Abducted in Syria, Civil Society Speakers Say, Demanding Information about Missing Persons’ Whereabouts,” (A/HRC/46/55), August 7, 2019, https://www.un.org/press/en/2019/sc13913.doc.htm, at para 23.

[4] UNHRC, Report of the Independent International Commission of Inquiry on the Syrian Arab Republic (A/HRC/46/55), March 11, 2021.

[5] Truth and Justice Charter: A Common Vision on the Question of Enforced Disappearance and Arbitrary Detention in Syria by Syrian Victims’ and Family Members’ Organisations, February 2021, https:/www.impunitywatch.org/truth-and-justice-charter-syria.

[6] UNHRC, “Assault on medical care,” note 1. (“The deliberate targeting of hospitals, medical personnel and transports, the denial of access to medical care, and ill-treatment of the sick and wounded, has been one of the most alarming features of the Syrian conflict”).

[7] For a discussion of field hospitals, see Rayan Koteiche, “My Only Crime Was That I Was a Doctor: How the Syrian Government Targets Health Workers for Arrest, Detention, and Torture,” Physicians for Human Rights, December 4, 2019, https://phr.org/our-work/resources/my-only-crime-was-that-i-was-a-doctor/.

[8] Personal communication with former health care worker detainee, October 9, 2021, on file with PHR.

[9] For a discussion of Syrian detention centers’ extortion practices, see Association of Detainees and the Missing in Sednaya Prison (ADSMP), “Forcibly Disappeared in Syrian Detention Centers,” December 2020, https://www.admsp.org/wp-content/uploads/2021/07/Forcibly-Disappeared-in-Syrian-EN.pdf.

[10]  Joseph Holliday, “The Assad Regime: From Counterinsurgency to Civil War,” The Institute for the Study of War, March 2013, http://www.understandingwar.org/sites/default/files/TheAssadRegime-web.pdf.

[11] Andrew Osborn, “Russia begins Syria air strikes in its biggest Mideast intervention in decades,” Reuters, September 30, 2015, https://www.reuters.com/article/us-mideast-crisis-russia/russia-begins-syria-air-strikes-in-its-biggest-mideast-intervention-in-decades-idUSKCN0RU0MG20150930; Christiaan Triebert, “How Times Reporters Proved Russia Bombed Syrian Hospitals,” New York Times, October 13, 2019, https://www.nytimes.com/2019/10/13/reader-center/russia-syria-hospitals-investigation.html.

[12] The main Syrian security services are the Department of Military Intelligence (Shu`bat al-Mukhabarat al-`Askariyya); the Air Force Intelligence Directorate (Idarat al-Mukhabarat al-Jawiyya); the Political Security Directorate (Idarat al-Amn al-Siyasi); and the General Intelligence Directorate (Idarat al-Mukhabarat al-`Amma).

[13] For an overview of the intelligence system, see Andrew Rathmell, “Syria’s Intelligence Services: Origins and Development: Origins and Development,” Journal of Conflict Studies 16, no. 2 (1996): 75-96.

[14] UNHRC, Report of the Independent International Commission of Inquiry on the Syrian Arab Republic (A/HRC/46/55), March11, 2021, at para 15. 

[15] “Syria protests: Assad to lift state of emergency,” BBC News, April 20, 2011, https://www.bbc.com/news/world-middle-east-13134322.

[16] Human Rights Watch, “Syria: Counterterrorism Court Used to Stifle Dissent,” June 25, 2013, https://www.hrw.org/news/2013/06/25/syria-counterterrorism-court-used-stifle-dissent.

[17] Diwan, “Local Coordination Committees of Syria,” Carnegie Middle East Center, https://carnegie-mec.org/diwan/50426?lang=en.

[18] Open Society Justice Initiative (OSJI), a team of human rights lawyers and staff pursuing strategic litigation and other legal work to promote global human rights, national security, and more, https://www.opensocietyfoundations.org/who-we-are/programs/open-society-justice-initiative; Syrian Network for Human Rights (SNHR), an independent human rights organization working to monitor, document, and combat human and civil rights violations in Syria, https://sn4hr.org; Violations Documentation Center (VDC), a project of the Syrian Center for Media and Freedom of Expression that has worked since 2011 on documenting violations of human rights law and international humanitarian law in the context of the Syrian conflict, https://www.vdc-sy.info/index.php/en/about.

[19] For the governorate of detention, the team used references to cities, neighborhoods, towns, and other geographic identifiers to determine the governorate. The team used the most recent administrative map of Syria to distinguish between Damascus (Dimashq) and Rural Damascus (Rif Dimashq). When health care workers were detained while traveling between two different governorates and it was unclear where the detention occurred, the team recorded the governorate from which they were traveling.

[20] Data for professions was initially organized into 11 groups: surgeons, non-surgeon physicians, non-specified physicians, dentists, pharmacists, veterinarians, nurses, technicians, health science students, non-health background, and unknown. The “non-health background” group was composed of people without advanced training in health sciences, such as ambulance drivers, first aid providers, medical equipment distributors, and non-health sciences students. Note that some nurses included in this group may have four-year university degrees. The data does not distinguish between two- and four-year degrees for nursing.

[21] UN Office of the High Commissioner for Human Rights (OHCHR), “Definition of enforced disappearances,” https://legal.un.org/ilc/sessions/71/pdfs/english/cah_un_wg_disappearances.pdf.

[22] Only numbers equal to or greater than zero were accepted.

[23] The team made exceptions in three instances: one in which governorate of origin differed between two cases, but every other variable matched, including the person’s first name, father’s name, and family name; and two other instances where a single variable conflicted between cases, but the notes sections included detailed references to other detention events in the data set.

[24] Microsoft Corporation, (365), Microsoft Excel, retrieved from https://office.microsoft.com/excel.

[25] StataCorp, 2019, Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC.

[26] Written account on file with PHR MENA team.

[27] There is no authoritative figure for the total number of those arbitrarily detained or forcibly disappeared by the Syrian government, although the UN CoI estimates tens of thousands over the past decade. This is not a comprehensive analysis of detention-related events; however, the sample allows insight into trends in outcomes among individuals providing health care.

[28] This means that there were 1,644 cases in the data set that were initial detention events and 41 cases where a health care worker was detained for a second, third, or fourth time.

[29] As discussed in the methodology section, there are limitations on the information in the data set due to the unavailability of information about deaths and releases from the Syrian government, and the stigma of detention that may have contributed to the undercounting of detainees, and especially women.

[30] UNHRC, “Out of Sight, Out of Mind: Deaths in Detention in the Syrian Arab Republic,” February 3, 2016, A/HRC/31/CRP.1, https://www.refworld.org/docid/56b9f4c24.html.

[31] StataCorp, 2019, Stata Statistical Software: Release 16, College Station, TX: StataCorp LLC; All odd ratios were statistically significant with P values less than .001, unless otherwise noted.

[32] Physicians’ ability to leverage social networks and wealth may have decreased over time. The CoI noted in March 2021 that a wide range of corrupt practices involving extortion, bribery, and “exploiting family members’ desperate pursuit of information” have increased due to the worsening economic situation. CoI, March 11, 2021, (A/HRC/46/55), para 108.

[33] For a discussion of the importance of social networking and “wasta” generally, see Annika Kropf, “Wasta as a Form of Social Capital? An Institutional Perspective,” in Tanya Cariina Newbury-Smith, The Political Economy of Wasta: Use and Abuse of Social Capital Networking, 2016.

[34] CoI, A/HRC/46/55 para 108, note 32 above.

[35]  Elisabeth Longuenesse, “Ingénieurs et médecins en Syrie: formation, emploi, statut social” Tiers-Monde, tome 36, n°143, 1995. (“The situation of the doctor is relatively favorable compared to the engineer or any other high-level profession: private practice ensures him at worst an income three times that of a university professor.”), PHR’s translation.

[36] For examples, see Human Rights Watch, “If the Dead Could Speak: Mass Deaths and Torture in Syria’s Detention Facilities,” December 16, 2015, https://www.hrw.org/report/2015/12/16/if-dead-could-speak/mass-deaths-and-torture-syrias-detention-facilities; ECCHR, “Photographs and data from the Caesar-File Group,” https://www.ecchr.eu/fileadmin/Hintergrundberichte/Background_Syria_Torture_CaesarFiles_GermanyCriminalComplaint_ECCHR_August_2019.pdf.

[37] UNHRC, “Out of Sight, Out of Mind.”

[38] PHR “My Only Crime Was That I Was a Doctor.”

[39] All names of team members are pseudonyms that PHR generated.

[40] PHR researchers reviewed the images and videos of Abdullah’s, Hassan’s, and Ibrahim’s bodies.

[41] Note that all names are pseudonyms. Interviews were conducted as research for the PHR report “My Only Crime Was That I Was a Doctor.”

[42] The “exceptional” courts were established for use during armed conflict by Legislative Decree No. 109 of 17 August 1968, which was amended to include periods of “domestic unrest.” See, Mikael Ekman, ed, “ILAC Rule of Law Assessment Report: Syria 2017,” International Legal Assistance Consortium, April 2017,http://www.ilacnet.org/wp-content/uploads/2017/04/Syria2017.pdf.

[43] Syria protests: Assad to lift state of emergency,” BBC News, April 20, 2011, https://www.bbc.com/news/world-middle-east-13134322 (cited above at note 13).

[44] In this report, the term “health care worker” refers to individuals who, at the time of attack or detention, were engaged professionally or as volunteers in the search for, or collection, transportation, diagnosis, or treatment of the wounded and sick (including provision of first aid) and in the prevention of disease.

[45] Rick Gladstone and Malachy Brown, “In Syria, Health Workers Risk Becoming ‘Enemies of the State,’” New York Times, December 4, 2019, https://www.nytimes.com/2019/12/04/world/middleeast/syria-health-workers-persecution.html.

[46] “Law 19, Anti-Terrorism Law,” http://www.parliament.gov.sy/arabic/index.php?node=55151&cat=4306.

[47] The Tahrir Institute for Middle East Policy, “Brief: Law No.19 of 2012: Counter-terrorism Law,” January 7, 2019, https://timep.org/reports-briefings/timep-brief-law-no-19-of-2012-counter-terrorism-law/. See also: Syrian Network for Human Rights, “At Least 10,767 Persons Still Face Trial in Counter-Terrorism Court, nearly 91,000 Cases Heard by the Court,” October 15, 2020, https://reliefweb.int/report/syrian-arab-republic/least-10767-persons-still-face-trial-counter-terrorism-court-nearly.

[48] Syrian Arab Republic’s Constitution of 2012, “Chapter II: Rule of Law,” 11, https://www.constituteproject.org/constitution/Syria_2012.pdf?lang=en.

[49] Abduction, assault, and kidnapping are all prohibited by the Syrian Penal Code (1949).

[50] For IHL to apply, the conflict between the government and the insurgents must meet a level of intensity in which the government “is obliged to use military force … instead of mere police forces.” In order to be a “party to the conflict,” a non-state armed group must possess a command structure and the capacity to sustain military operations. For a detailed introduction to the issue, see ICRC opinion paper, “How is the Term ‘Armed Conflict’ Defined in IHL?” March 2008, https://www.icrc.org/en/doc/assets/files/other/opinion-paper-armed-conflict.pdf.

[51] International Committee of the Red Cross (ICRC), The Geneva Conventions, August 12, 1949, 36, https://www.icrc.org/en/doc/assets/files/publications/icrc-002-0173.pdf.

[52] Customary International Humanitarian Law, ICRC, “Rule 99: Deprivation of Liberty,” Vol. II, Ch. 32, Sec. L.; Customary International Humanitarian Law, ICRC, “Rule 90: Torture and Cruel, Inhuman or Degrading Treatment,” Vol. II, Ch. 32, Sec. D.; Customary International Humanitarian Law, ICRC, “Rule 98: Enforced Disappearance,” Vol. II, Ch. 32, Sec. K.; Customary International Humanitarian Law, ICRC, “Rule 89: Violence to Life,” Vol. II, Ch. 32, Sec. C.

[53] Customary International Humanitarian Law, ICRC, “Rule 25: Medical Personnel, Vol. II, Ch. 7, Sec. A; Customary International Humanitarian Law, ICRC, “Rule 26: Medical Activities, Vol. II, Ch. 7, Sec. B.

[54] OHCHR, International Covenant on Civil and Political Rights, Art. 7, 9 10, 14, rat. March 23, 1976, https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx.

[55] UN General Assembly, Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 10 December 1984, United Nations, Treaty Series, vol. 1465, p. 85, https://www.refworld.org/docid/3ae6b3a94.html.

[56] OHCHR, International Covenant on Economic and Social Rights, Art. 12, rat. January 3, 1976, https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx.

[57] OHCHR, “About arbitrary detention,” https://www.ohchr.org/EN/Issues/Detention/Pages/AboutArbitraryDetention.aspx.

[58] Report of the Working Group on Enforced or Involuntary Disappearances, January 26, 2011, https://undocs.org/A/HRC/16/48.

[59] UN General Assembly resolution 70/175, annex, adopted on December 17, 2015, https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf.

[60] It is worth noting that the Syrian government has released only a few prisoners during the COVID-19 pandemic, despite fears of mass infections. Suleiman Al-Khalidi, “Syria slow to free prisoners despite coronavirus risk in crowded jails: rights groups,” Reuters, April 6, 2020, https://www.reuters.com/article/us-health-coronavirus-syria-jails/syria-slow-to-free-prisoners-despite-coronavirus-risk-in-crowded-jails-rights-groups-idUSKBN21O1WO.

[61] UN General Assembly, Rome Statute of the International Criminal Court (last amended 2010), 17 July 1998, ISBN No. 92-9227-227-6, https://www.refworld.org/docid/3ae6b3a84.html.

[62] ICRC, Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), 8 June 1977, 1125 UNTS 3, https://www.refworld.org/docid/3ae6b36b4.html.

[63] Diane Orentlicher, UN independent expert, “Updated Set of principles for the protection and promotion of human rights through action to combat impunity,” Economic and Social Council, E/CN.4/2005/102/Add.1, February 8, 2005, https://documents-dds-ny.un.org/doc/UNDOC/GEN/G05/109/00/PDF/G0510900.pdf?OpenElement.

[64] Report of the Working Group on Enforced or Involuntary Disappearances, January 26, 2011, https://undocs.org/A/HRC/16/48.

[65] UNHRC, Report of the Independent International Commission of Inquiry on the Syrian Arab Republic (A/HRC/46/55),March 11, 2021, para 105.

[66] Diagnoses include prolonged grief disorder (PGD), post-traumatic stress disorder (PTSD), and major depressive disorder (MDD). L.I.M Lenferink, et al, “Cognitive-Behavioral Correlates of Psychological Symptoms Among Relatives of Missing Persons,” J Cogn Ther 11,311–324 (2018).

[67] See note 9.

[68] Fadwa Mahmoud, Families for Freedom, as cited in Jeremy Sarkin, “Humans not Numbers: The Case for an International Mechanism to Address the Detainees and Disappeared Crisis in Syria,” May 2021, https://cad5e396-f48c-4e90-80f5-27ccad29f65e.filesusr.com/ugd/f3f989_ea155e7ebd6940d1b4a11cd0057af7d0.pdf.

[69] Truth and Justice Charter, at note 4.

[70] The organizations include The Association of Detainees and Missing Persons in Sednaya Prison, Caesar Families Association, the Coalition of Families of Persons Kidnapped by ISIS (Massar), Families for Freedom, and the Ta’afi Initiative.

[71] For a detailed discussion of the proposed mechanism, see Jeremy Sarkin, “Humans not Numbers.”

[72] The countries who have adopted universal jurisdiction legislation include Canada, Finland, France, Germany, The Netherlands, Norway, Sweden, and Switzerland. For an overview of the comparative legal frameworks in each country, see TRIAL International, “Prosecuting International Crimes: a Matter of Willingness,” May 5, 2020, https://trialinternational.org/latest-post/prosecuting-international-crimes-a-matter-of-willingness/.

[73] See e.g., “Joint Statement by Iran, Russia, Turkey on the International Meeting on Syria in Astana, 23-24 January 2017,” p.1, https:/www.peaceagreements.org/viewmasterdocument/2092. For a brief overview of the process, see France 24, “Syria: the Astana peace process,” September 5, 2018, https://www.france24.com/en/20180905-syria-astana-peace-process.

[74] Four UN Security Council resolutions on Syria (UNSC 2139, 2254, 2268, 2474) have addressed arbitrary detention and enforced disappearances. The UN Special Envoy for Syria has emphasized the need to release detainees and abductees and clarify the fate of missing persons in the third, fourth, and fifth Brussels Conference Co-chairs declarations. Regrettably, the recommendations from PHR’s 2019 report on the targeting of health care workers, “My Only Crime Was that I Was a Doctor,” still apply.