Syria: COVID-19 under the government service

22. June 20217. April 2022 Ahmad Khanshour

Dr Mohamad Katoub

Dr Mohamad is a dentist, and humanitarian and human rights activist. Mohamad is a former humanitarian aid worker and advocate whose 10 years of experience focuses on monitoring violations against health, and he is a Research Fellow at the Syria Impacts Study, University of California, Berkeley School of Public Health

On 28 May 2021, Syria was elected a member of the World Health Organization (WHO) Executive Board for a three-year period, along with Afghanistan, Belarus, Denmark, France, Japan, Malaysia, Paraguay, Peru, Rwanda, Slovenia and Timor-Leste. WHO is made up of three bodies – the World Health Assembly, the Executive Board and the Secretariat, while its governance structure also includes a general director, regional offices, and technical committees. This structure provides extensive powers to the Executive Board, which is responsible for implementing WHO policies and has powers to set funding for emergency responses, approve the budget, nominate the General Director, set the time and place of special sessions, and many other tasks. The WHO Executive Board is made up of 34 representatives designated by other member states for a three-year term.

Syria’s membership of the WHO Executive Board was not subject to open voting. Based on WHO’s constitution, a secret voting process takes place after the country nominates itself to the General Committee, which must submit nominations to achieve a balanced distribution of the Executive Board as a whole. However, in the event that the number of candidates does not exceed the number of vacant seats, the election carries out in light of no objection, which is what happened in Syria’s election(1) where the voting was based on rule 80 of rules of procedures(2) of the health assembly which looks like the most common practice in those elections. In case the number of candidates is more than the vacant seats, or any state member of the health assembly put an objection, then a secret ballot would be conducted. There is nothing stated in the organization’s regulations either the constitution, or rules of procedures that indicate the possibility of reversing or cancelling this decision.

This seat will allow the Syrian government significant influence over the decisions of WHO, which was never, either in its response to Syria or in responses to other countries, immune to political influence from these countries in which it operates. In fact, it was never immune to the Syrian government’s interference in its operations – from needs assessment, to implementation, procurement, recruitment, and even monitoring and evaluation (3). There are dozens of examples of interference by the Syrian regime, either to politicise the humanitarian response and use it as a weapon of war against opposition communities, or to benefit companies and investments that are closely affiliated to it, contracting with the Syrian Ministry of Defence and circumventing US and European sanctions which included the Syrian Minister of Health, Hassan Ghobash (4), who will represent the Syrian government on WHO’s Executive Board.

WHO financed the Syrian Ministry of Defence blood bank (5) with nearly USD five million, and the United Nations offices have spent more than USD 12 million for the Four Seasons Hotel, which the Syrian government owns a third of, and has contracted with the Syriatel Company, owned by Rami Makhlouf the cousin of Bashar al-Assad. United Nations agencies have no means to pressure the Syrian government, which obstructed delivery of 90% of humanitarian convoys.

Ghobash, as Minister of Health for this government will represent Syria over a period of 3 years along with 34 representatives of member countries on WHO Executive Board. This will allow him to build relationships, network, exchange interests, and voice opinions in decision-making and policies of WHO at a very critical time in which the organization is leading the health response to the COVID-19 epidemic around the world.

The health response in Syria is facing serious challenges, which have been greatly exacerbated in 2020 and thereafter due to the COVID-19 pandemic. The Syrian government’s handling of the pandemic depicts vividly what Syria’s membership of the WHO Executive Board will look like.

The Syrian government in the face of COVID-19

In March 2020, the former Syrian Minister of Health, Nizar Wahbi Yazigi (6), stated that no COVID-19 cases were detected and that the Syrian Arab Army had “cleansed many germs present in Syria” in reference to the military operations against the opposition, in which Bashar al-Assad called his opponents “germs”. At the end of 2020, Syria submitted a request to join the COVAX Initiative. At the beginning of 2021, the parliament passed a law approving the agreement between the Syrian government and Gavi, the Vaccine Alliance. The official Syrian News Agency reported Ghobash, who succeeded al-Yazji as health minister in August 2020, as saying in his speech to parliament that the agreement will create savings in foreign exchanges and the government is seeking to obtain vaccines against coronavirus under several conditions, the most important of which is not compromising Syrian state sovereignty (7). These statements by successive health ministers illustrate the mentality of the Syrian regime and its successive governments. The army can do it all, including disinfection of ‘germs’, and national sovereignty is the number one priority even in responding to the COVID-19 pandemic, before the health of citizens.

COVID-19 impact on humanitarian needs in Syria

The impact of pandemics goes beyond health, as they affect the country’s economy, livelihoods, and other sectors. In contrast, the ability of any country to respond to an epidemic goes beyond the capabilities of its health system. The logistical capabilities to secure the needs of society through the speed of adaptation to work, education, and transportation constitute a cornerstone in the ability of any government to respond to pandemics. All of this was not taken into account by the Syrian government even before 2011, so how would the situation be after ten years of exhausting the country’s resources in the war against its people (8)? How will the impact of the virus be in a country with only 64% of its hospitals, and 52% of healthcare centres functioning, while pharmaceutical factories operate at only 5% of capacity? This is due to the bombing of these facilities and the inability to cover running expenses due to deteriorating economic conditions.

In 2020, the need for humanitarian response in Syria increased as a result of the pandemic. The percentage of Syrians living below the poverty threshold reached up to 90%, while the unemployment rate surpassed 50% and the need for humanitarian response increased by 20% in one year (9). Consequently, the number of people in need of humanitarian assistance in Syria increased to 13.4 million, more than 50% of them in severeneed of assistance in health, shelter and education.

The Syrian government’s response to the COVID-19 pandemic

The Syrian government lacked transparency in declaring numbers of infected cases, and there was no capacity to provide screening tests to cover total needs. This capacity varied from one region to another within Syrian government areas based on government satisfaction with the political attitudes of these communities. For instance, all areas that were retaken by the Syrian regime still lack fundamental health services, such as Daraa, Eastern Ghouta, and the Eastern neighbourhoods of Aleppo city (10). Additionally, there is a large discrepancy in the magnitude and quality of the response among areas of military governance outside Syrian government control. Figures issued by health authorities in these areas reflected weaknesses in transparency and testing capacity rather than the extent of epidemic spread in Syria. Several reports highlighted the expansion of corruption around COVID-19 testing, with people who needed a negative test for travelling purposes getting one for a few hundred US dollars without any test being conducted. Testimonies of many health-workers documented the weaknesses of protection and prevention provided to medical staff in government-controlled areas (11).

Statements issued by health officials contradict official figures declared by the Syrian government. Dozens of media and human rights reports confirm that cases are much higher than reported and the government exerts pressure on doctors to hide the real numbers. In August 2020, the Assistant Health Director of Damascus reported that COVID-19 cases in Damascus and its countryside exceeded 110,000 (12). In early 2021, the Syndicate of Syrian Doctors announced the death of 130 doctors in Syrian regime-controlled areas because of the pandemic (12). In spite of human rights reports documenting the Syrian government’s use of the pandemic to justify deaths under torture in the detention centres (14), the death of 130 doctors in government-controlled areas is not compatible with Ministry of Health data shared with WHO, which stated the number of affected health personnel as 282. Such inconsistencies between what the Syrian government declared and the numbers occasionally leaked indicates the Syrian government’s manipulation of numbers.

The table below (153) provides information shared by health authorities of the three main areas of control in January 2021, at the same time as the statement by the head of the Syrian Doctors Syndicate about 130 deaths. It shows significant discrepancies in the numbers shared with the United Nations and the periodic leaks from Syrian health officials.

Total deaths among health staff	Total injuries among health staff	Total injuries	Region
130	282	12462	Government-controlled areas
10	2618	20717	Northwest Syria
	761	8227	Northeast Syria

Vaccines via COVAX

In late April 2021, the first batch of AstraZeneca vaccines arrived in Syria (16), divided into 203,000 to the Ministry of Health in Damascus for Syrian government-controlled areas and areas under control of the Syrian Democratic Forces in Northeast Syria, which receive humanitarian aid through the cross lines convoys since the closure of the humanitarian border crossing at Al-Yarubiyah in January 2020 following Russian veto (17). In addition, 53,800 doses went to the Syrian Immunisation Group (18), an alliance of non-governmental institutions providing immunisation in Northwest Syria. The Syrian government also received 150,000 vaccine doses as a gift from the Republic of China (19).

Northeast Syria after cross-border closure

Health responses in Northeast Syria provide an example of what happens if humanitarian aid passes to areas outside Syrian government control through the United Nations offices in Damascus. Joan Mustafa, head of the Health Authority in the Autonomous Administration of Northeast Syria, announced (20) at the end of last May that they had received 17,500 doses of COVID-19 vaccine from the COVAX initiative. The Executive Board of the Autonomous Administration mentioned 23,000 doses in a summary published on their Facebook page, condemning the politicization of the health response (21) as the quantity is not proportional to the population or what was sent to other areas. It is clear that there is no serious coordination by WHO with the health authorities that provide services in cooperation with NGOs in northeast Syria for more than two million citizens. Until the beginning of June, there is no information about whether these vaccines will cover areas outside Syrian government control in the northeast, or only areas controlled by the Syrian government (22). Whereas the number of people receiving vaccines exceeded 19,000 in areas of northwest Syria that get humanitarian aid across the border (23), and the number of people who received the vaccine exceeded 70,000 in areas controlled by the Syrian government (24), there is no information about the numbers who received the vaccine in Northeast Syria.

In all of Northeast Syria, there is one PCR device in Qamishli, which means a large proportion of swabs travel up to six hours by road to reach the device daily and it takes two or more days to obtain results. This device provides services to two million citizens. There are 117 facilities providing health services in Northeast Syria, including 10 hospitals and 7 health centres equipped to serve coronavirus cases. For example, in Deir Ez-Zor governorate, there is one hospital providing health services for COVID-19 patients and an isolation centre with a capacity of 12 patients for acute and moderate cases that do not need intensive care. In recent months, there has been a significant decline in financing the running costs of most of these facilities (25). The impact of the closure of the Yarubiyah border crossing for humanitarian aid in Northeast Syria is clear. Although there are UN agency offices in Qamishli, these offices follow UN offices in Damascus and cannot do anything without approval of the Syrian government. Availability of medical supplies for emergency response has decreased by 40% and 30% of patients with chronic diseases in displacement camps in Northeast Syria do not receive medications. In 2021, the aid gap exceeded USD 26 million in comparison with last year.

Majed, a primary health care worker from Deir Ez-Zor governorate said: “Screening tests take two to three days, and sometimes even more, to know the results. Tests are collected from four teams working in the governorate and all are sent to the city of Qamishli, with the only PCR machine in the Northeast region of Syria. We are trying to obtain means to cover the logistical expenses of delivering samples from Deir Ez-Zor to Qamishli, and many other expenses. Most patients are isolated at home, as there are two isolation centres with very weak capacities in all of the governorate.” Majed continued: “Insufficient resources have been allocated to conduct awareness campaigns. For citizens, scarce awareness campaign funds were spent to cover other necessary operational expenses.”

During the 15 months of fighting the pandemic, president al-Assad has not mentioned the pandemic in any of his few speeches. We did not see any Syrian official dedicating their time to addressing Syrian citizens about the response, measures taken by government, upcoming challenges, and plans to address them. Citizens seem like a commodity to be sold and bought by the Syrian regime. The health system is not a priority compared to national sovereignty, and the Ministry of Health plans based on army triumphs. This government does not mind keeping small areas crowded with hundreds of thousands, such as detention centres, without services or a large geographical area inhabited by two million Syrians, such as Northeast Syria, without a response. It does not mind using the pandemic, the humanitarian response, and the country’s economy for its interests and the interests of those close to it. This government won a seat among 34 countries leading the world’s health policies at a very critical time. WHO can only provide the highest degree of transparency to the world in this response. What example do the Health Assembly member states provide by allowing the Syrian government a seat in the Executive Board? What example would the UNSC provide by allowing the Syrian government to have more influence on humanitarian aid in case they don’t reauthorize the cross border resolution in July 10^th ?

References

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