The Syrian Civil War: March 2011 - Present

Source: New York Times Online, 20151

Outline of Presentation

• Syria: Location & Main Players Conflict

• What were the causes of the Syrian Civil War?

• Health and health systems impact of conflict?

• Impacts of the humanitarian response to Syrian crisis?

• The opportunities for and barriers to future health and peace in Syria?

• Conclusion

• Syria lies in South-western Asia and is bordered by Turkey, Iraq, Jordan, Israel and Lebanon.2

• Bashar al-Assad came to power in 2000 and was president of the Alawite Ba’ath Party when the 2011 Civil War began.3

• Long-standing history of human rights abuses and military coups – 1982: 40,000 were killed in the Muslim Brotherhood uprising against Hafez al-Assad. 3

• Main players in conflict are Syrian Armed Forces (Shi’a) , Free Syrian Army (Sunni), People’s Protection Unit (Kurdish) & ISIS (Salafi Jihadism).3

Syria: Overview

Source: Vincentions in Syria, 20152 & BBC, Syria Profile 20153

Q1) WHAT WERE THE CAUSES OF THE SYRIAN CIVIL WAR?

ETHNIC repression?

KURDS

ARABS

Al Matawirah tribe which Bashar al-Assad belongs to comprises

2.5% of the population4

VS

Nowruz = Arresting without warrant under Emergency Law since 1963 – allowed to

prohibit events which “incite sectarian, racial or religious strife”5

SUNNI ALAWITE

LEGAL isolation?

SYRIAN PENAL CODE – ARTICLE 288:

CRIMINALISES JOINING “WITHOUT PERMISSION OF THE GOVERNMENT ANY POLITICAL ORGANISATION. . . WITH AN INTERNATIONAL CHARACTER.”6

NO ENFORCEABLE POLITICAL PARTY LAW PRIOR TO MARCH 2011 UPRISING.6

RELEGATED OTHER POLITICAL PARTIES TO BE VIEWED AS UNLICENSED SECRET ORGANISATIONS.7

POLITICAL failure?

Economy: Sweeping Economic Reforms under IMF Guidance high unemployment, devaluation of Syrian pound. 8

Oil Industry: Price of diesel nearly tripled between 2007 and 2009.9

Climate & Agriculture: 85% of livestock lost due to drought in Northeastern Syria11 & 2-3 million in extreme poverty. 10

Reflective of the ‘new’ wars theory?• The growing impotence and declining legitimacy of the established political classes12

• Insecurity associated with globalization causing conflict12

” It is not so much the extent of inequality as the kind of inequality that is likely to

matter.”13

- Christopher Cramer

LIBYA:Gadhafi16

SYRIA: Bashar al-Assad

TUNISIA: Ben Ali14

EGYPT: Mubarak15

Conclusion• Certain ethnic groups cannot

have legitimacy and freedom whilst others can

• Certain political voices can be heard, whilst others are muted

• When Syrian’s want to protest against a regime which has

failed them their human right to do so is repressed

Q2) WHAT HAVE BEEN THE HEALTH AND HEALTH SYSTEM

IMPACTS OF THE SYRIAN CRISIS?

Effects of conflict on HEALTH SYSTEM:Syrian Health System

Infrastructure Human Resources Medicines Electricity

60% of hospitals destroyed18

Aleppo should have 2,500 doctors, only

36 remain.18

Production at present has now fallen by 70%.19

83% of the lights have gone out in Syria20

233 attacks on health facilities17

Half of all doctors in Syria have fled18

Syria produced 90% of its medicines before conflict19

No MRI device in Aleppo, nearest is in

Manbij - 54 miles away18

BEFORE THE CONFLICT: 2011

DURING THE CONFLICT: 2014

Source: BBC, UN Security Council Failing Victims (2015)21

Effects of conflict on HEALTHHealth of Syrians

Conflict Related Injuries

NCDs: the “silent” burden Maternal Health

Over one million

injuries22

2012 = 70,000 cancer patients not

receiving treatment23

Little to no mental health services available,

only two hospitals and one referral centre.24

Tens of thousands of Syrians now

require prostheses and long-term rehabilitation22

Raqqa – ISIS stronghold =

no obstetric or gynecology service for

1.6 million women26

200,000 deaths from chronic conditions17

Communicable Disease

WHO estimates over 7,600 Syrians are currently

infected with Polio25

Gaps in evidence

Targeting of hospitals, patients and medical staff = heightened reluctance for patients to visit hospitals need for deterioration of violence

Health needs of refugees who do not reside in camps, or besieged individuals = largely unknown, but expected to be considerable

• Lack of safety for experts to conduct research

Q3) WHAT HAVE BEEN THE IMPACTS OF THE HUMANITARIAN

RESPONSE IN SYRIA?

Barriers to Humanitarian Impact in Syria

FUNDINGA twelvefold increase in humanitarian

needs over the last three years (from 1 to 12 million) with funding increasing

threefold from $639m to $1.8bn in 201427

2012 2013 2014 20150

5

10

15

20

25

30

Funding for OCHA's Syria Response

Funding Required

Funding Received

Years

mill

ion

US$

% Funded 137% 113%% 97% 24% Source: OCHA Website

Source: OCHA Website28

Barriers to Humanitarian Impact in Syria

LEVEL OF CARE

• Emergence of Exceptional Care Committees to make decisions according to prognosis and cost of illness: In Jordan

between 2010-2012 only 48% of applications for cancer treatment were permitted. 29, 30

Unusually harsh use of military weapons = high demand for sophisticated medical care

Barriers to Humanitarian impact in Syria

FAILURE OF SECURITY COUNCIL?

“Calls upon all parties to immediately lift the sieges of populated areas”31

- UN Security Council Resolution 2139: Feb 2014

212,000 people remain in besieged locations & corridors of

access diminished by 63% compared to 2013 levels31

Barriers to Humanitarian success in Syria

INDIVIDUALS OUTSIDE OF

REFUGEE CAMPS

Humanitarian’s administering of IDs to refugees = aware of family size, deliver rations, tents, & set up water

… However, bureaucratic problem when trying to find, register and give aid to refugees outside camps.

People outside of camps are probably in a worse state of health, we know less about them and high numbers of children are in this unstable position giving rise to child

trafficking32, 33

Broadening of the humanitarian role in Syria?

Adaption needed rather than remodelling of purpose: need to mitigate regional destabilisation by assisting neighbouring countries, heighten co-ordination and mobilise funding

The answer Syria needs is not a humanitarian one, but a political one.

Cannot base humanitarian impact on health indicators alone, need to take into account environment, protection, education and affordability of care.

Q4) THE OPPORTUNITIES FOR AND BARRIERS TO FUTURE

HEALTH AND PEACE IN SYRIA?

BARRIERS to future peace & health

• High Levels of Violence34 • Lack of political will?35, 36

- June 2012 – Geneva Communiqué = set up of transitional government including members of current regime to arrange free elections: resolutions on paper, lack of change on the ground

- 2014 – 2015: Geneva II, Moscow Talks I/II: main armed & political groups absent & travel bans

• Proliferation of rebel groups36, 37

1000+ distinct rebel groups Group fragmentation with divergent preferences the set of agreements that all parties

will accept is smaller longer duration of war Informational theory: Process of warfare reveals information allowing parties to form

realistic view on their probability of victory Information asymmetry: in multiparty conflict the information revealed is often difficult to interpret longer duration of warj

OPPORTUNITIES for future peace & health

• Geneva Communiqué?

The Geneva Communiqué remains the only communiqué, and the only paper, to have been agreed upon by everyone; Russia, to the US, from the region onwards

Discuss appointment of humanitarian envoy to give day-to-day political pressure to deliver aid - e.g. Operation Lifeline Sudan during Sudan Civil War in 1990s 39

• “Freeze” in Aleppo:

Staffan De Mistura negotiated a “freeze” of violence in Aleppo between government and opposition – potential to spread to Daraa, Huta, Damascus38

Conclusions

CAUSES OF WAR: Ethnic tensions, legal isolation, political failure & endemic inequality of human rights combined to provoke the riots of

March 2011.

HEALTH & HEALTH SYSTEM IMPACTS:Shattered medical infrastructure, mass

exodus of health workers and deterioration of medicine production

severe decrease in health outcomes e.g re-emergence of polio & access to

treatment for NCDs

HUMANITARIAN IMPACTS:Success impeded by lack of funding, expense of health care provision and

failure of Security Council to enact political pressure to open access

corridors need for adaption

FUTURE HEALTH & PEACE:Barriers = extreme levels of violence and a

lack of political will to overcome it. Opportunities = “freeze” of violence, &

operisation of Genva communiqué Syrian led, Syrian inclusive formula

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