As the civilian death toll from conventional and chemical weapons in Syria mounts, politicians and policymakers around the world are locked in debate about how to respond.
Away from the question of military intervention the British prime minister, David Cameron, pledged an additional £52 million in humanitarian aid to Syrian civilians. Britain is one of the largest donors, along with the US and the United Arab Emirates, Kuwait and other Gulf countries. The provision of healthcare and humanitarian aid is one of the ways to assist and protect civilians.
One study attributes a declining battle-related death toll in armed conflict to the changing nature of warfare, to public health campaigns and to the increase in the provision of humanitarian assistance in war and armed conflict.
Tragically, humanitarian aid and health-care providers face a range of constraints in trying to establish or maintain operations to all areas in Syria. Not least of these is their own physical security. Operating on or near the front lines of battle makes providing health care and humanitarian assistance a hazardous profession. Syria is no exception.
Like civilians in Syria, aid workers and health-care providers are caught in the crossfire, stopped at checkpoints and injured or killed by mortars, bombs, and bullets. In May, a British doctor working for a UK charity was killed when the hospital in which he was working was shelled. Working with the International Committee of the Red Cross to provide health care and other assistance, the Syrian Arab Red Crescent has lost 20 volunteers in three years.
International organisations and their partners provide much-needed assistance in Syria. The vast majority of health-care providers in Syria, however, are Syrian doctors and nurses. They work in local hospitals and clinics under sub-optimal and dangerous conditions, often without much-needed supplies.
International agencies working in these environments have calculated that the risks of operating are justified given the level of need in Syria. They adopt a range of measures to protect their staff, ranging from travelling in armoured vehicles to building trust. They educate the government, rebels and others about the principles of independence, neutrality, and impartiality that make humanitarian work possible.
Hurdles and hazards
Although physical security is an ongoing concern, a significant issue for health care and other humanitarian providers is gaining permission to operate in Syria. The Syrian government has instituted bureaucratic hurdles that hinder their work. In some cases the government has denied humanitarian agencies permission to operate in Syria, declaring it “illegal” and forcing them to operate in secrecy.
The Syrian government has permitted some assistance to rebel-held areas from within Syria. To date it has not allowed the United Nations or other humanitarian agencies to conduct “cross-border” operations to rebel-held areas from Turkey. As a result, Human Rights Watch has reported that “insufficient aid” is reaching opposition controlled areas and has called for cross-border operations.
Diplomatic pressure on Syrian authorities must include reminders of their responsibilities under international humanitarian law to ensure that humanitarian agencies are given permission to operate in all areas of Syria.
When it is too dangerous
Given the dangers and access constraints, many organisations are unable or unwilling to operate in Syria, or they operate through local partners, such as the Syrian Arab Red Crescent. In some cases — when the risks are too high — organisations make the difficult decision to not be present or to withdraw.
The decision to withdraw is not one organisations take lightly. The humanitarian organisation, Médecins Sans Frontières recently pulled out of Somalia, after 22 years of continuous presence. MSF operated in Somalia for many years given often-precarious security conditions. It lost 16 staff, including 11 Somali staff members, during that time.
MSF’s decision to withdraw was “heartbreaking”, according to the MSF-US Executive Director, Sophie Delaunay, and reflected what they saw as a loss of consent and acceptance.
As long as you feel there is a strong acceptance and a willingness from those who claim to be the leaders in this environment to protect your work or at least to try to defend our presence, we could stay in Somalia with a high level of risk. But if these guarantees no longer exist, then it seems to us that it was impossible to stay in the country.
Prior to its departure, MSF treated approximately 50,000 patients per month in Somalia, patients who are now left without access to healthcare.
In Syria, given the high levels of physical risk, the plethora of armed actors, and the challenges of access, ensuring acceptance and consent for the provision of healthcare is especially challenging. Without this, Syrian civilians will continue to be denied access to healthcare and assistance, both of which could save lives.