PHOTO: A health worker administers polio vaccine to child during a UNICEF-supported vaccination campaign in Damascus in 2013 (AP/UNICEF)

Annie Sparrow, an aid worker and health care practitioner with experience inside Syria, writes for Middle East Eye about the relationship between the UN’s World Health Organization and the Assad regime.

Sparrow argues that the WHO’s “endorsement” of the regime’s claims about public health are hiding a catastrophic situation. She adds that this catastrophe has been compounded by the regime’s systematic attacks on medical facilities and personnel.

The WHO has responded to some of Sparrow’s points in a separate article published by Middle East Eye:

For years now, the World Health Organization has been fiddling while Syria burns, bleeds and starves. Despite WHO Syria having spent hundreds of millions of dollars since the conflict began in March 2011, public health in Syria has gone from troubling in 2011 to catastrophic now.

To put this in perspective: life expectancy for someone born in the US has risen half a year from 78.7 years in 2010 to 79.3 years in 2015. Over the same time period in Syria, it has plummeted more than 15 years from 70.8 years in 2010 to 55.4 years in 2015.

This devastating figure is comparable with South Sudan (57.3) and considerably lower than Afghanistan (60.5), Rwanda (66.1), and Iraq (68.9). Disturbingly, the global average life expectancy for babies born in 2015 is 71.4 years, but baby boys in Syria can expect to live just 48 years and baby girls 65 years.

Even Haitian babies can expect to live an average of 63.5 years, despite two centuries of political turmoil and the worst rates of infectious diseases such as HIV and cholera in the Western hemisphere.

The reason for Syria’s plummeting public health can be illustrated by the final, devastating fall of eastern Aleppo.

Systematic Bombing

Like the residents of Moadamiya, Homs, and Darayya before them, the last 250,000 civilians of eastern Aleppo and 10,000 members of militia succumbed after months of siege on top of years of systematic targeting of civilian homes, hospitals, schools and shops using missiles, barrel bombs, chemical attacks, bunker busters, incendiary weapons and cluster munitions.

The main attackers have been the Syrian government of Bashar al-Assad and its principal allies, Russia mainly from the air, with support on the ground from Iran and Hezbollah.


Destroyed hospital in Idlib Province in northwest Syria

Tens of thousands of civilians were evacuated from eastern Aleppo to the western Aleppo countryside and Idlib governorate, both still controlled by opposition groups such as Ahrar al-Sham (the major rebel force) and Jabhat al-Nusra (the Al Qa’eda affiliate until it recently rebranded itself, claiming it had parted ways with the group).

Such dislocation only exacerbates the health crisis faced by roughly 2.5 million civilians in Idlib – those displaced and their host communities – and the half-million plus in opposition-controlled parts of western Aleppo. And that’s not even counting the additional four million civilians living in other opposition-held areas, more than one million of which live in areas still besieged by the government.

That increases the need for WHO Syria’s assistance, which should be delivered according to need, the principle of impartiality, one of WHO’s founding ethical principles.

Yet WHO Syria has been anything but an impartial agency serving the needy. As can be seen by a speech made by Elizabeth Hoff, WHO’s representative to Syria, to the UN Security Council (UNSC) on 19 November 2016, WHO has prioritized warm relations with the Syrian government over meeting the most acute needs of the Syrian people.

Reflecting this misprioritization, Hoff’s presentation was rife with inaccuracies, scanty on facts, and deeply skewed to favour the Syrian regime. This bias can be illustrated by three particularly disturbing parts of her presentation.

Misrepresentation of Infectious Diseases

First with respect to infectious diseases – a matter of global concern because germs do not respect borders – Hoff spun the Syrian government’s efforts positively while concocting a central life-saving role for her WHO office. She claimed that before the conflict, “national vaccination coverage rates were 95%” but now, “almost six years later… vaccination coverage rates have dropped by half”.

She also testified to the Security Council that polio, a life-threatening childhood illness that re-emerged in Syria in 2013 after being eliminated in 1995, was “re-eradicated thanks to concerted efforts by WHO and UNICEF”.

In fact, although the Syrian government insist that the national polio vaccination coverage rate for 2009 and 2010 was 99%, WHO and UNICEF estimate that it was only 83% – and even this figure was accorded their lowest grade of confidence due to the lack of supporting data. These estimates and the contrasting “official figures”, are cited in WHO and UNICEF’s 2013 Global Polio Eradication Initiative Strategic Plan for Polio Elimination in the Middle East.

Indeed, one reason behind the 2011 uprising in Syria was the years of the Assad regime withholding standard vaccinations of children – which protect them from diseases such as polio, pertussis and measles – in areas considered politically unsympathetic, such as the provinces of Idlib, western Aleppo, and Deir Ezzor, while pro-regime areas such as Damascus and Tartous received full coverage. The Syrian government insists measles coverage was 99 percent in 2010, and claims 100 percent coverage for immunization against diphtheria, pertussis and tetanus (DPT) in contrast to WHO and UNICEF estimates of 82 percent and 87 percent respectively.

Hoff’s endorsement of the government’s inflated vaccination claims help cover up its politicisation of this fundamental form of healthcare. More to the point, though Hoff may not know it given her lack of medical expertise, if national coverage rates had really been as high “before the conflict” as she and the Assad government insist, polio would never have re-appeared in 2013.

That is because the spread of polio requires herd immunity – the protection conferred on the whole population when immunization coverage reaches a critical threshold – to drop below 80-86 percent. It would take well over three years for herd immunity to drop from “99 percent” to anywhere approaching this level, particularly given the concomitant drop in the crude birth rate and fertility.

Moreover, Hoff associates the risk of polio and other crippling and deadly diseases to unvaccinated children with the conflict. This rationalization that polio is the result of conflict – reflected as well in WHO’s 2014 report “Polio: War in Syria opens the door to an old enemy” – is often repeated by the Syrian government. But blaming conflict by itself is lazy, and wrong.

Polio did not reappear in Iraq throughout the entire eight years of the Iraq war (2003-2011), yet broke out in Syria after a mere two years of war – and then spread to Iraq, almost certainly as a result of the forced displacement of civilians from northeastern Syria.

Polio’s re-emergence in Syria is consistent with pre-existing low immunisation rates and the vulnerability of Syrian children living in government-shunned areas such as Deir Ezzor, Aleppo and other northern governorates.

All cases of polio in Syria broke out in areas that had long been opposed to the Assad regime, reflecting the political dimension of the outbreak.

Not a single case occurred in territory controlled by the government. In Deir Ezzor, where polio first re-appeared in 2013, polio vaccination coverage had dropped to 36 percent. This was a man-made outbreak. Hoff ignored all of this.

Polio Cover-Up

When polio did reappear in July 2013, the Syrian Ministry of Health hid it for months, insisting that its Early Warning Alert and Response System, set up in September 2012 with the technical help and sole financial support of WHO, was reliable.

Then, in the first week of October 2013, samples from a cluster of crippled children in Deir Ezzor smuggled cross-border for analysis in Turkey were also sent to the National Lab in Damascus.

Damascus first insisted that the samples were contaminated, then that they showed Guillain-Barre syndrome, even though this syndrome is determined by clinical diagnosis, not by a laboratory test.

Only in October 2013, did the Syrian Health Ministry concede that an outbreak of polio was underway after undeniable laboratory proof was provided through the coordinated efforts of doctors working inside conflict areas, the opposition-supported Assistance Coordination Unit (ACU), the Turkish government, and the US Centers for Disease Control (CDC).

Hoff’s claim that polio was “re-eradicated thanks to concerted efforts by WHO and UNICEF” is a breathtakingly outrageous attempt to rewrite history and take credit where none is due.

In fact, as noted, WHO had nothing to do with the discovery or containment of the polio outbreak, toeing the government line during the critical early stages of the polio outbreak, denying the re-emergence of polio for months, and endorsing the government’s surveillance system as it failed to detect the outbreak.

Only after independent proof made denial impossible did WHO finally acknowledged polio’s reappearance in Syria on 29 October 2013, the day after the Syrian Health Ministry did.

As for containing the polio outbreak, credit belongs to the independent Polio Control Task Force (PCTF), a group of Syrian and international health NGOs formed to address the polio emergency in the absence of effective government, with a network of 8,000 volunteers across northern governorates.

It was supported by the Turkish government, which helped it to purchase vaccines independently of WHO and its UN sister organisation, UNICEF. Without WHO’s or UNICEF’s assistance, the PCTF vaccinated 1.4 million children over the course of eight separate vaccination campaigns conducted in seven governorates, achieving a coverage rate of 92 percent. That stopped polio in its tracks.

The PCTF was supported in this effort not by WHO or UNICEF, which the Syrian government prohibited from taking part, but by the International Rescue Committee (IRC), the International Medical Corps (IMC), and the Turkish and French governments.

Hoff’s self-congratulation for a campaign that WHO was barred from supporting by the same government that created the conditions that made polio’s return possible, also fails to mention the many medical staff and volunteers who lost their lives during this vaccination campaign as a result of the targeted air strikes of the Assad regime’s air force.

Further, WHO’s reliance on the government’s limited and politicized public health surveillance and reporting extends beyond polio.

In Cholera in the time of war, published by the British Medical Journal of Global Health in October 2016, my colleagues and I describe similar problems with respect to cholera – another disease that reflects both the pre-war neglect and the subsequent deliberate war-time destruction of the public health system in opposition areas.

The Syrian government suppressed most information about a cholera epidemic that broke out in 2009 as well as cholera deaths of several children that occurred in October 2015.

Killing Medics, Bombing Hospitals

The second troubling aspect of Hoff’s testimony in November concerns her mention of “the repeated attacks on healthcare facilities in Syria”.

She cited a figure of 126 such attacks between January and September 2016, yet fails to note that the chief perpetrator of these attacks was the Syrian regime, joined by its Russian ally.


Rescuers move through the rubble of the bombed al-Quds hospital in eastern Aleppo city, April 2016

According to Physicians for Human Rights, of some 400 attacks on 276 separate healthcare facilities between March 2011 and July 2016, Syrian and Russian forces have been responsible for more than 90 percent.

Of the 768 medics killed during this period as documented by PHR, 713 (almost 93%) were killed by the Syrian and Russian government forces.

These attacks parallel the government’s targeting of civilians in opposition-held areas, where roughly seven million civilians live.

From 1 August to 30 November 2016, the Syrian American Medical Society documented 112 additional attacks on health facilities of which 111 were committed by pro-regime forces. These attacks are included in a SAMS report released earlier this month.
Since August, at least another 29 healthcare workers have been killed, as documented by the Syrian Network for Human Rights, bringing the total to 797, of which 742 (93 percent) were killed – on duty – by pro-regime air strikes.

Hoff again failed in her testimony to mention any of this.

See No Evil, Speak No Evil

Beyond refusing to name the perpetrators of these attacks, Hoff clouded the issue by describing the “militarization of healthcare facilities by several parties to the conflict” as “another visible violation,” as is “the targeting of medical personnel”.

Insofar as such militarization exists, it is an insignificant problem compared with the Syrian and Russian government’s targeting of health facilities where there was no militarization in sight.

Indeed, Syrian doctors who have been in contact with non-state military groups such as the Free Syrian Army, Ahrar al-Sham, and even Jabhat al-Nusra told me that these groups have requested that hospitals not be built anywhere near their military bases, as they do not want to suffer the collateral damage when the hospitals are targeted by the Syrian air force.

It is typical that Hoff’s testimony, given less than 24 hours after the last trauma hospitals in eastern Aleppo were destroyed by targeted Syrian and Russian air strikes, including the only pediatric hospital, makes no mention of these attacks, or of the civilians killed.

Hoff also failed to describe the consequences of these incessant air strikes on health facilities.

For example, Hoff noted without specification that pregnant women do not have access to safe delivery, but pregnant women in government cities such as Damascus, Tartous, Sweida, Lattakia, Quneitra do have access to safe delivery, obstetricians and blood transfusions.

It is only in opposition-held areas that healthcare is compromised because of the damage and destruction resulting from air strikes by pro-government forces.

In Eastern Ghouta, for example, home to 450,000 civilians, almost 600 babies are born each month, yet there are only a few obstetricians.

Meanwhile, the attacks on hospitals make it too dangerous for pregnant women to spend hours there as they undergo normal labour. Instead, they must have Caesarean sections. The rate for C-sections in heavily targeted areas such as eastern Aleppo (until its fall) and Eastern Ghouta, according to data collected by physicians that I have spoken with and corroborated by SAMS, has been 60 to 70%.

This is more than double the US average for low-risk Caesarean sections of 26%.

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