The intentional use of health as a weapon of war has not only prevented Syrians from seeking appropriate care for injuries, but also exposed them to emerging and re-emerging diseases, ranging from polio and tuberculosis, to the latest bout of cholera. It has also weakened all infrastructural resilience and health or humanitarian responses to large-scale disasters, as we continue to witness thousands of lives being lost after the tragic February 6 earthquake due to overwhelmed local capacities and deadlocked aid responses, especially in Syria’s northwest, despite the best efforts of the Syria Civil Defense, also known as the White Helmets.
While the 11th year of conflict in the country has displayed relatively lower levels of armed violence, continued forced disappearances, airstrikes, bombings, and intermittent clashes on various frontlines remain a major source of insecurity. Other forms of insecurity also endanger the lives of millions of Syrians, as they struggle with pervasive poverty, protracted famine, and reduced access to various basic necessities. Amidst rampant fuel and food shortages, over 15.3 million Syrians are estimated to be in need of humanitarian aid in 2023, with over 90 percent of the population living below the poverty line. Additionally, the scarcity of access to clean drinking water leaves a large share of Syrians with no other choice than to rely on alternative untreated water sources, vectors of a wide range of water-borne diseases.
As an infamous disease of poverty, cholera thrives in conflict-afflicted countries where access to safe drinking water and adequate sanitation cannot be guaranteed. Cholera has permeated various governorates, regardless of territorial control. While the first cases were mainly concentrated in Aleppo, the wave of infections soon also overwhelmed northeastern and northwestern Syria, posing a particularly grave danger in the Idlib camps’ informal settlements, suffering from overcrowding, insanitation, and lack of running water.
The Syrian régime deliberately cut off access to and bombed water sources, such as the Ain al-Fijeh spring in 2016 situated a few kilometers northwest of Damascus, when punishing populations. Other actors, mainly ISIS, also employed water as a weapon of war, by not only destroying pipes and sanitation plants, but also poisoning water sources and calculatingly flooding cities. As such, less than 50 percent of water and sanitation systems are currently functional nationwide. As main treatment facilities have come to a halt, over 70 percent of sewage is untreated waste.
Just like water was used as a weapon to force the opposition into submission and regain control of territories, it is currently deployed as a political tool to coerce and capture loyalties through politicized reconstruction, excluding those opposed to the régime. While one of the main reconciliation promises extended by the Syrian régime was to reinstate public social services in formerly rebel-held territories, the state only confiscated and co-opted the public facilities established by the disbanded opposition councils, including field hospitals and water infrastructure, but in a politicized manner, conditioning access to these services on political allegiance.
Similarly to water, health has also been used as an instrument and target of violence. The Syrian state’s violence was distinctly characterized by the systematic targeting of health infrastructure. From the very early days of the revolution, most state-hospitals were militarily subverted as government forces stationed inside to capture incoming patients, or used them as a military base for snipers to fire from, as has been the case for the national hospital in Deraa. Over time, such focus on hospitals as political spaces evolved into full scale airstrikes, bombings, shelling, shootings, and artillery attacks penetrating the vicinity of health facilities, with over 600 attacks conducted between 2011 and early 2022. The Syrian régime and allied forces bear the responsibility of more than 90 percent of these attacks, which have intensified after Russia’s involvement in 2015, bolstering the air and ground campaign aimed at suppressing opposing political and military forces. The persecution, torture, and killing of health personnel, coupled with their enrolment to conduct medicalized killings and torture, as exemplified by the trial of the Syrian doctor Alaa M. for crimes against humanity, have further contributed to exhausting the country’s health capacities. The remains of this fragmented health governance architecture operate in secluded silos, unable and unwilling to communicate key data points to trace and contain outbreaks.
During the COVID-19 outbreak, under-reporting was prevalent, owing to a lack of preparedness, testing capacities, but also of political will. The Syrian régime’s strategy today echoes similar lines of political reasoning, as the government fears demonstrating weakness through its inability to provide basic social services to a struggling population. This would undermine the state-propagated narrative presenting Syria as safe for return.
With cholera cases spreading to Lebanon, and given the precedent set by the global response to COVID-19, the régime also fears facing stringent measures that would further reduce the mobility flows of people and goods. Yet, not only is the state misrepresenting the real toll of the disease, deep public distrust also prevents many in régime-held territory from seeking healthcare due to fear from persecution in infiltrated healthcare facilities, leading to greater disconnect between official public health figures and the reality on the ground.
Yet, not only is the régime failing to contain the outbreak in the territories it holds, it is also actively repressing efforts to contain it in areas that fall outside of its control. Given the destruction wrought by the weaponization of water and health, rebel-held areas in northwest Syria rely on humanitarian aid. Continued cross-border humanitarian aid delivery rests on the renewal of the United Nations Security Council’s authorization every six months, which the Syrian government has previously attempted and successfully managed, to restrict, by closing off the Bab al-Salam, al-Ramtha, and al-Yarubiyah crossing points. Under the constant threat of Russia’s possible veto, failure to renew access to the remaining Bab al-Hawa access point could deprive the region from essentials needed to contain the cholera outbreak, including treatment, hygiene kits, and chlorine tablets.
The Syrian ministry of health has received 2 million cholera vaccines from the UN in November 2022 for its exclusive benefit, with cholera vaccination coverage currently predominantly concentrated in areas under its political control. Similarly, the so-far limited international aid received by Syria, whether sent via bilateral or multilateral canals operated by organizations such as the Syrian Arab Red Crescent, has been channeled into government-held areas. This leaves little possible oversight to ensure it is directed indeed toward relief efforts and not diverted for other purposes, while also further isolating the northwest whose situation remains dire.
As such, concentrating aid in Damascus allows the Assad régime to continue politicizing aid by selectively providing medical and humanitarian aid to areas it wants to reward loyalty in, while withdrawing it from those deemed to be opposing it.
Any long-term solution will be contingent upon serious changes in the political and socioeconomic context, ones that hold the current Syrian régime accountable for its long series of crimes against humanity and provide an opportunity for Syrians to rebuild a country where freedom and democracy are inalienable rights.'
