An enormous humanitarian crisis may face the four million people in Syria’s northwest region, specifically the Idlib governorate, which currently relies on one lifeline to outside aid: the Bab al-Hawa border crossing from Türkiye. In the months leading up to the outbreak of the COVID-19 pandemic in late 2019 and early 2020, Idlib faced heavy aerial bombardment that targeted health workers and destroyed medical infrastructure. The violence was part of a Syrian government strategy in the country’s decade-long conflict of systematically attacking health care facilities and personnel in opposition-held areas.

The intense bombardment led to a major increase in internally displaced people in Idlib, who already numbered more than one million at the start of the pandemic. A recent UN briefing shows an emergency threshold of acute malnutrition, particularly among displaced children in Syria’s northwest. Displacement and malnutrition increase people’s risk of exposure to COVID-19 as well as their risk of severe outcomes if they contract the virus. This population, and an additional three million civilians across Syria’s northwest, are critically reliant on aid distribution reaching them through the Bab al-Hawa border crossing from Türkiye.

Dr. Yasser Najeeb, chair of the Technical Committee of the Syria Immunization Group (SIG) – the main consortium responsible for distributing vaccines –  shared with PHR his on-the-ground perspective regarding the Bab al-Hawa crossing. “There is fear about the Bab al-Hawa crossing possibly closing,” Dr. Najeeb said in a phone call. “If it closes, it will be devastating.”

The aid that reaches the northwest through the Bab al-Hawa crossing is designated by the UN Security Council through resolution 2533. The Security Council votes annually to renew these UN-administered border crossings that deliver humanitarian aid convoys to civilians inside Syria. With the most recent annual renewals, more of the border crossings have closed, due to vetoes by permanent Security Council members Russia and China. As of June 2020, only the Bab al-Hawa crossing to Idlib remains open. This renewal is set to expire on July 10, 2021.

The Bab al-Hawa crossing must remain open – not only to supply critical aid, but also to address the ongoing COVID-19 pandemic

Last June, ahead of the 2020 border crossing renewal, PHR’s director of policy, Susannah Sirkin, briefed the Security Council, noting that “despite record-level cross-border aid deliveries into northwest Syria, the humanitarian needs remain overwhelming” and called on the Council to “enable humanitarian assistance through all available channels and to renew the cross-border aid resolution to secure access to lifesaving aid for the four million Syrians in need.” The same call stands today and is just as urgent, if not more so.

Vaccine distribution to the Northwest

More than half of the recorded COVID-19 cases in Syria have been in the northwest, where the COVID-19 tracking system is more sensitive in capturing cases. On April 21, 53,800 AstraZeneca vaccines were delivered to the northwest through the Bab al-Hawa crossing as part of the international COVAX initiative. With this shipment, Dr. Najeeb explained, the SIG plans to first vaccinate doctors and health care providers, then humanitarian workers, and then move to inoculate those over 60 or with comorbidities.

The plan to vaccinate IDPs is similar to the larger vaccine rollout plan across Idlib. “When we move to vaccinate those in certain age groups and those with comorbidities, this will include those in the camps,” said Dr. Najeeb. The SIG plans to eventually have 10 vaccination centers across the camps, when there are enough vaccines. It hopes to achieve a 60 percent full vaccination rate soon, which would require 2,500,000 people across northwest Syria to be vaccinated. To underscore the challenge of reaching this goal, COVAX, the main current supplier of vaccines, is only scheduled to deliver a total of 1.5 million vaccines to northwest Syria this year, according to current distribution plans, and has fallen behind projections in many parts of the world due to lower-than-expected production. In the immediate term, while pursuing larger-scale supply improvements, high-income countries should send already-purchased doses of the vaccine to COVAX to facilitate larger shipments to Syria’s northwest until the SIG’s goal of two-thirds vaccination is achieved.

In the meantime, the SIG says it has not been made aware of a second shipment date for COVID-19 vaccines. What’s more, the batch delivered in April entered through the Bab al-Hawa crossing – and the continuation of that access depends on a critical Security Council vote before the resolution expires on July 10.

The Bab al-Hawa crossing must remain open – not only to supply critical aid, but also to address the ongoing COVID-19 pandemic, including access to vaccines. Along with maintaining the northwest crossing, the Security Council should also reopen the other three crossings, al-Yarubiyah, al-Ramtha, and Bab al-Salam, particularly as residents in some areas retaken by the Syrian government face documented discrimination that has impeded their access to health. It would be unconscionable for the Security Council to block lifesaving help for the millions of women, men, and children who depend on it in this devastated area of Syria.

Among the many impacts of the COVID-19 pandemic, its effects on mental health have proven to be widespread and substantial. In January 2021, four out of 10 adults in the United States reported symptoms of anxiety or depression disorder – a 400 percent increase from January 2019. Health care workers are particularly exposed: more than half of workers on the front line could be at risk for one or more mental health problems, alongside the health risks involved in working with COVID-19 patients.

Children are also facing a mental health crisis during the pandemic. Emergency department visits by children for mental health issues went up about 30 percent for kids ages 12-17 and 24 percent for children ages 5-11 between March and October of 2020. Unstable learning environments, prolonged isolation, housing insecurity, systemic racism, and various other factors are all making children vulnerable to burnout. Burnout is characterized by symptoms of physical or emotional exhaustion caused by long-term stress.

Children and health care workers of color are especially at risk, compounding the effects of systemic racism.

Physicians for Human Rights (PHR) hosted a discussion on the mental health impacts of the pandemic and solutions to expand and encourage access to mental health care as part of PHR’s COVID-19 webinar series. PHR Board Member Gail Saltz, MD moderated the discussion. She was joined by Felton Earls, MD, emeritus professor of human behavior and development at Harvard T.H. Chan School of Public Health and emeritus professor of social medicine at Harvard Medical School; Jessica Gold, MD, MS, assistant professor and director of wellness, engagement, and outreach at the Washington University School of Medicine; and Matthew Howard, DNP, RN, CEN TCRN, CPEN, CPN, director of scholarship and leadership resources at Sigma Theta Tau International Honor Society of nursing, part-time staff nurse in the emergency department at Eskenazi Health in Indianapolis, and nursing faculty in the graduate and doctoral programs at Northern Kentucky University.

Front Line Workers and Pandemic Burnout

In the webinar, panelists talked about how health care workers are especially susceptible to burnout. Health care work can be psychologically and physically draining, yet this often goes unnoticed. Even before COVID-19, physicians had the highest suicide rate among every profession, and nurses had higher suicide rates than the general population.

Only three percent of psychiatrists are Black, posing further barriers to Black health care workers looking for help.

“Most of us work 12-hour shifts at a facility or a hospital,” Howard, a frontline nurse, said. “We do see patients the entire time. One of the biggest things, in the emergency department at least, is, as we start, we’re gowned, we’re gloved, we’re masked, and we pretty much stay that way the entire time.” This can be extremely mentally and physically taxing, as being fully gowned, masked, and gloved can make someone more hesitant about attending to their own physical needs during their long shift.

Health care workers of color have been at a particular disadvantage during the pandemic, Dr. Gold pointed out. They are dying in more significant numbers than white health care workers and are less likely to seek out mental health services. Importantly, only three percent of psychiatrists are Black, posing further barriers to Black health care workers looking for help.

Much of the struggle comes from rapidly changing work environments, where health care workers are experiencing things that are painful to process. Many have never said out loud that what they are seeing is hard and “That they’re allowed to say that, that they’re allowed to have feelings, that they’re allowed to be struggling, and that coming to me is not a weakness in any sort of way,” Dr. Gold said.

Pandemic Burnout in Children

The pandemic has also left children, particularly those in Black and brown neighborhoods, without the usual mentorship and support they would receive from their communities, families, and educators, according to Dr. Earl. Accessibility is an important factor for children experiencing the pandemic, as a lack of resources can substantially change how children navigate online learning.

In wealthier neighborhoods, schools have the resources to accommodate children in safer ways, including the implementation of hybrid schooling. “Those students who are attending private schools and schools that are open more than closed are having their stress buffered more than those in neighborhoods dealing with racial injustice, at the same time the consequences of the pandemic, and the combined impacts of those two epidemics on children has to be considerable,” Dr. Earl said.

So, what can be done to support health care workers and children experiencing burnout?

One important step is building trust. “Having the experience and the belief that the organizations around you, the schools, the health care centers, the businesses, and government, are working for you and not against you is the most important single factor,” Dr. Earl said.

“Those students who are attending private schools and schools that are open more than closed are having their stress buffered more than those in neighborhoods dealing with racial injustice.”

Felton Earls, MD, emeritus professor of human behavior and development at Harvard T.H. Chan School of Public Health and emeritus professor of social medicine at Harvard Medical School

And while individual efforts to improve burnout are helpful, Dr. Gold stressed that real change needs to be enacted systemically. “The system has to acknowledge it has a problem,” she noted. “We have to say, hey, we’ve had a problem for a long time, and a lecture on burnout is not going to fix it.”

Instead, what is needed are long-term financial investments in addressing the mental health issues facing health care workers, alongside advocacy for more supportive work environments.

As for children, they must be supported in ways that respect their ideas and emotions, Dr. Earl suggested. The impact of the pandemic and systemic racism cannot be reversed or diluted, but there is value in honoring the ways children have been feeling during these difficult times.

This fact sheet was produced in partnership with Doctors for Camp Closure, Doctors for America, and Human Impact Partners.

A year after the Trump administration introduced a specious order using public health as a pretext to end asylum at the border, President Biden and the Centers for Disease Control and Prevention (CDC) continue to use the order to expel hundreds of thousands of asylum seekers to danger. Carried out under a provision of U.S. health law – section 265 of Title 42 – these expulsions cause extensive suffering and harm under the guise of public health. The Title 42 order was issued despite widespread objections from epidemiologists and health experts, who have refuted its public health justification and issued detailed recommendations on safely processing asylum seekers during the COVID-19 pandemic. At this moment, we have an opportunity to right the wrongs of the past by following science-based public health policies and ensuring the safety of children, families, and adults seeking asylum. The Biden administration must end this expulsion policy, restore asylum at the border, and welcome asylum seekers with respect.

What is the Title 42 order and how is it being used to block asylum seekers?

Early in the pandemic, the Trump administration exploited the emergency to completely close U.S. doors to asylum seekers at the border, while continuing to allow many other, non-asylum- seeking travelers across. On March 20, 2020, the CDC issued an order citing section 265 of U.S. Code Title 42 (U.S. health law), allowing the U.S. federal government to immediately turn away and expel people arriving at the border seeking asylum protection. Such actions constitute violations of U.S. and international law. The order, which can be rescinded at any time, has been used by the Department of Homeland Security to carry out more than 750,000 expulsions and to essentially eliminate asylum at the border, resulting in dire humanitarian consequences, such as the severe overcrowding of families in migrant shelters and encampments in northern Mexico.

There is no public health rationale to categorically exclude asylum seekers while millions of other travelers cross the border without testing or contact tracing.

The Title 42 order is not based on public health rationale or data. It was implemented despite objections from senior CDC medical experts and it has been widely criticized by public health and medical experts, who state that the order has no scientific basis as a public health measure. International borders remain largely open to other travelers. People fleeing persecution are protected under U.S. and international law, and the United Nations Refugee Agency (UNHCR) has confirmed that countries must not deny entry or discriminate against asylum seekers solely because of the COVID-19 pandemic.

However, in spite of promising to bring humanity to the immigration system, President Biden has yet to repeal the Title 42 order; on May 19, 2020, it was extended indefinitely, with the CDC director stating the order will continue “until I determine that the danger of further introduction of COVID-19 into the United States has ceased to be a serious danger to the public health, and continuation of the Order is no longer necessary to protect the public health.” More than 70 million pedestrians and vehicle passengers were permitted to enter the United States through ports of entry on the U.S.-Mexico border from April to December 2020 without testing or tracing, while a much smaller number of asylum seekers have not even had the chance to have their case heard.

Banning only asylum seekers asking for protection in the United States is discriminatory, racist, and puts thousands of lives at risk.

The harsh consequences for children, families, and adults

The Biden administration has used the Title 42 order to block or expel asylum-seeking families and adults from Burkina Faso, Cameroon, Cuba, El Salvador, Ethiopia, Ghana, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Nigeria, Russia, Somalia, Venezuela, and Yemen. According to reports, there have been at least 492 violent attacks, including kidnappings, rapes, torture, physical assaults, and verbal threats, against asylum seekers turned away or stranded in Mexico during the current administration. Since February 2021, the U.S. government has put the lives of Haitians in direct danger by sending 27 airplanes with more than 1,400 adults and children, including asylum seekers, directly back to Haiti despite the political instability and violence there.

Shortly after children were exempted from the order due to pressure and litigation, parents stranded in northern Mexico were forced to make the difficult decision to send their children to the United States alone, as that was the only way they could ensure their safety, effectively causing new family separations and increasing the number of unaccompanied children in custody.

Although the Biden administration has started to accept 250 asylum seekers a day, effectively exempting them from the Title 42 order as part of negotiations in a federal court case, the Title 42 order must be revoked completely.

What is the alternative?

Instead of unlawfully shutting down access to asylum, the Biden administration must uphold U.S. values and refugee laws, listen to the guidance from public health and refugee experts, and welcome migrants with respect.

Scientific and medical research continues to show that social distancing, wearing masks, and home isolation are the most effective measures to limit the spread of the outbreak. Science- based public health measures can be implemented at U.S. borders that both protect the health of the American public, U.S. border officers, and communities on both sides of the border, as well as safeguard the lives of those seeking refuge and safety.

How you can take action

The Title 42 order relies on the justification that denying asylum access is good for public health. As such, the expertise of health professionals is crucial in correcting the narrative and demanding an end to the Title 42 border expulsions and this systematic violation of human rights. Here’s how you can take action:

• Sign our petition: Tell Biden that the Trump administration’s weaponization of the pandemic to expel asylum seekers under the guise of public health must be rescinded now.
• Tweet or share resources on your social media accounts.
• Share the reports “The Invisible Wall: Title 42” from Haitian Bridge Alliance and “Failure to Protect” from Human Rights First
• Write an op-ed or letter to the editor of your local newspaper to share your perspective, as a health professional, on the importance of restoring asylum.
• Raise the misuse of Title 42 in relevant professional forums such as conferences, association meetings, and webinars.
• Volunteer as a clinician or non-clinician with Refugee Health Alliance in Tijuana.