Months into the COVID-19 pandemic, the Syrian government was playing a dangerous game. It initially refused to acknowledge that there were any cases of the disease in Syria, creating an environment of misinformation and fear that was useful in its fight against dissidents. In March, the government finally started to acknowledge that there were a small handful of cases, but the numbers were likely significantly underestimated as the government continues its attempts at obfuscation. Despite the inadequate testing infrastructure and questionable transparency, there are now reports of 720 COVID-19 cases in Syria. A country already devasted by nine years of war and having experienced an estimated 500,000 deaths, must now brace itself for more as there are serious questions as to Syria’s ability to provide an effective public health response.
This situation was avoidable. It is no accident that Syria’s healthcare infrastructure is in tatters. The government has intentionally targeted hospitals, threatened healthcare workers, and denied and diverted humanitarian medical aid, particularly from non-government-controlled areas as a means of targeting rebels and the populations under their control. For example, reporting from the New York Times pieced together video evidence, along with cockpit radio communications showing that orders were given to bomb hospitals in Idlib province. Further evidence arises from the report of a United Nations Board of Inquiry (BOI) tasked by the U.N. Secretary General to investigate a so-called “deconfliction mechanism” which was used to share information between warring parties. While the mechanism was set-up to prevent attacks against hospitals and other objects protected by international humanitarian law, the BOI found that the Syrian government turned the system on its head and used the information for the purposes of targeting. The BOI also noted evidence of Russian involvement, but hedged on whether there was sufficient evidence to make a finding in that respect.
Hospital workers have likewise been the subject of intentional attacks by the Syrian government. This has led to an estimated 70 percent of health workers fleeing the country since the start of the conflict, leaving only a skeleton crew of medical workers to address any acute or chronic medical conditions.
The Syrian government also has a history of removing medical items from aid convoys traveling to opposition areas as a part of the larger strategy to control the flow of aid and ensuring that wounded or sick opposition fighters and civilians do not receive care and treatment. In February 2018, for example, Syrian authorities removed 3,810 medical treatments from aid convoys heading to Ghouta.
The Syrian government’s attacks on healthcare are further exemplified by the response to outbreaks of communicable diseases. For example, the reemergence of polio in Syria was a direct consequence of Syrian government’s deliberate inaction as it initially refused to acknowledge the existence of transmission and withheld routine immunizations in besieged and opposition-controlled areas such as Deir-Ez-Zor, where the outbreak began in 2013. The government attacked vaccine storage facilities leading to 140,000 doses of vaccine being destroyed. This led to 74 confirmed cases by 2017 for a disease that was on the verge of eradication.
The combined effect of these policies has been recognized by Dr. Annie Sparrow et. al. as the weaponization of healthcare namely, “a strategy of using people’s need for health care as a weapon against them by violently depriving them of it.” Though this concept aptly describes the strategy employed by the Syrian government, it does not fall neatly within the current structure of international humanitarian law (IHL) or international criminal law (ICL).
We have examined the criminal responsibility of the Syrian government from the perspective of IHL and ICL in a new paper. We assess the acts and omissions of the Syrian government in relation to its attacks on healthcare, including the incidents described above, as they apply to the weaponization of the COVID-19 pandemic. While direct casualties resulting from the Syrian and Russian bombing of hospitals clearly constitute war crimes, we conclude that indirect casualties resulting from the inaccessibility of healthcare may also lead to criminal responsibility as the foreseeable result of a coordinated campaign. This conclusion has a very real practical implication on the gravity of these crimes. Direct attacks on hospitals have resulted in hundreds of deaths. However, the Syrian government’s weaponization of healthcare has brought an appalling level of suffering and death, amounting to at least tens of thousands of victims. Syrians who die as a result of the inaccessibility to treatment or protection against COVID-19 may also result in criminal responsibility, in our view.
One challenge that arises is identifying the victims whose deaths are attributable to their inability to obtain healthcare or treatment. In this relation, there may be reference to the concept of excess deaths, the difference between observed numbers of deaths and expected numbers. To take one example, public health experts determined the number of deaths caused by the Ebola virus in West Africa that resulted due to the inaccessibility to healthcare. A number of conditions, including deaths of healthcare workers, mandatory curfews, etc., prevented many victims from receiving treatment and increased the numbers of casualties attributed to Ebola by thousands. The Syrian government’s intentional weaponization of healthcare has likewise deprived thousands of Syrians of treatment and it should be held criminally responsible for these outrages.
Still, it is relatively early in the outbreak of COVID-19 in Syria and a number of measures could, and should, be taken to reduce human suffering and risk of death. Humanitarian aid, including medical aid, should be allowed to flow into all areas. The United States should ensure that economic sanctions on Syria do not prevent humanitarian aid from reaching those in need. In particular, the existing humanitarian aid exceptions to the sanctions regimes should be clarified, including the provision of general and specific licenses to facilitate COVID-19 specific aid. Another obstacle to the provision of aid was the vetoes exercised by Russia and China of a UN Security Council resolution in early July that would have permitted cross-border aid into Idlib and Aleppo, resulting in a reduction in the number of approved entry points from six to one. Nonetheless, the Syrian government, of its own accord, should permit aid convoys to continue. It should also provide assurances that once a COVID-19 vaccine is developed, it will permit the WHO and humanitarian NGOs to disseminate the vaccine throughout the country, without discrimination against those in non-government held areas. This would show its willingness to prevent unnecessary human suffering and reverse its policy of weaponizing public health. The Syrian government should take note, however, that should it fail to adequately address the spread of COVID-19, senior members of the government may be held criminally responsible for the resulting deaths at the ICC or a future hybrid tribunal.
I will apply, for the benefit of the sick, all measures [that] are required […] I will prevent disease whenever I can, for prevention is preferable to cure. […] May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.
As COVID-19 threatens an already vulnerable population, the Syrian government must acknowledge the dangers posed by the disease and stop its attacks against healthcare in non-government controlled areas. Any less would be criminal.