This article was written by Nishanth Arulappan, independent researcher and doctor, formerly with Doctors Without Borders. The views expressed in this article are Arulappan’s own, and does not reflect the views of Doctors Without Borders. For more like this, see our public health newsfeed.
The humanitarian need in Syria has never been greater, but humanitarian efforts so far have been a Sisyphean task at best: just like Sisyphus was condemned to roll a stone up a hill only to find it roll back down, humanitarians have invested a lot in Syria, only to find themselves in the cross-hairs of the Syrian government and all their efforts are brought to naught.
While Albert Camus, the famous French writer, would have us believe that Sisyphus enjoyed his curse, no NGO that has faced operational reversals in Syria would acquiesce to that idea, and the utopian vision of “independent, neutral, and impartial” humanitarian action remains especially elusive in the Syrian context. Ban Ki-moon ceded failure in Syria as early as mid-2015, and the UN Security Council, having passed 24 resolutions, remains a venerable paper tiger — a colourful one, nonetheless — even as the conflict enters its ninth year.
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Humanitarian principles and assumptions are no match for the Machiavellian ambitions of the Syrian regime and its allies, and its “Realpolitik” doctrine is reflected in the way healthcare and humanitarian workers have been targeted in non-government controlled areas. Thus, an explicitly diplomatic platform — that can steer clear of political neutrality, and prioritise healthcare cooperation despite the conflict — is required if any system-level gains in health are to be made in Syria.
Healthcare has been weaponised in Syria: the healthcare needs of vulnerable populations are used a weapon by depriving them of it. Despite passing UNSC 2286 — which forbade attacking healthcare facilities and workers — the regime has systematically and deliberately increased such targeting to shift the power-balance in favour of the regime, by satisfying two main objectives: tactically, the lack of healthcare coerces population migration into government-controlled territories; strategically, it denies legitimacy to other actors providing healthcare in non-government controlled areas. Law No. 19 of the Counterterrorism Court criminalises the provision of medical aid to any non-governmental actor deemed “terrorist” by the Syrian government.
Humanitarian actors lack political clout which renders them vulnerable in in Syria
The Syrian Government has subtly misappropriated a $30 billion UN-led humanitarian budget, and thus managed to override the negative effect of the sanctions. The negotiated access granted to the UN, is eyewash, as their convoys have been stripped of all essential medical and surgical supplies, while the bureaucratic red-tape serves to ensure that only 2 to 18 percent of the UN’s aid actually reaches those in need.
Humanitarian actors lack political clout which renders them vulnerable in in Syria. Expecting them — with their exclusive focus on “saving lives” — to deliver long-term in the Syrian context, where there is a dire lack of respect for humanitarian principles, is both unrealistic and unreasonable. Humanitarian funding philosophies also render sustainability impossible: several underground hospitals in Syria are crowdfunded, as humanitarian donors are unwilling to fund the construction of hospitals, viewing this as a “development” concern.
A damaged hospital in the north of Syria. (picture credit: Nishanth Arulappan)
Assad has voiced a $400 billion bill for reconstructing Syria and most Western states are wary of post-war engagement in Syria, as long as the regime shows no behavioural change. Law no 10 allows for seizure of property and reallocation for reconstruction purposes.
This is an attempt to reshape the demographic make-up of Syria with a largely homogenous pro-Assad population. Hesitancy in delaying reconstruction will prolong the suffering of vulnerable populations, but any unplanned and premature intervention is guaranteed to be misappropriated by the Syrian government.
The complexity of the situation has created a Catch-22 situation for any state-level engagement for reconstruction in Syria.
What we need to do
No single state can shoulder the responsibility of reconstruction of healthcare in Syria and thus, a diplomatic platform — a “Health Coalition” so-to-speak — of states willing to engage in health-system development in Syria needs to be formed.
It can begin as a bilateral endeavour, progress to a multilateral level, and eventually incorporate regional and informal elements. This Health Diplomacy Platform (HDP) requires: (1) Access, (2) Influence, and (3) Mediatorial Potential.
Access is required to legally enter Syrian territory with explicit acknowledgement and protection from the highest levels of the Syrian government, and the HDP has to maintain a direct bilateral-type communication line with other state-level players in the conflict. Influence of a special kind would be ideal: the ability to coerce an outcome without having to resort to the threat of economic sanctions or kinetic military power.
A proven track record for mediatorial potential is mandatory, given the multitudinous players in the complex geopolitical landscape. A state that has these characteristics should take the lead in forming the HDP and invite others to join to “cooperate despite the conflict” for health Syria.
Historically, such cooperation occurred during the Cold War when the U.S. and the U.S.S.R collaborated to develop the Apollo-Soyuz Test Project, which served to defuse tension on both sides. Albert Sabin and Mikhail Chumakov jointly developed and tested the Polio Vaccine with remarkable success. Thus, science diplomacy served to secure cooperation despite strategic hostility and should serve as an example for health diplomacy (and can be expanded to other sectors as well).
Calling states to action
Science diplomacy involved strictly bilateral interactions, but there are numerous state-level players in the Syrian conflict with differing geo-strategic aims. Thus, the HDP should constructively channel the dynamics and interactions in a rational and resilient manner.
The reasons for policy failure should be explored on a systems-thinking basis, early warning systems should be designed to detect indicators, and course-correction measures should be deployed in a timely manner.
Politically neutral humanitarian attempts to engage in Syria can be rendered quixotic, and thus, a diplomatic platform comprised of states willing to invest in health reconstruction should be formed to engage and leverage the playing field in a cautious and progressive manner. — Nishanth Arulappan
(Photo credit: Nishanth Arulappan)