Residents of the besieged Rukban camp in southeast Syria await an aid convoy

It is time to state the disheartening conclusion: United Nations humanitarian operations in Damascus have surrendered to the demands of the Assad regime.

The UN’s Office for the Coordination of Humanitarian Affairs (OCHA) says 11.7 million Syrians, about 70% of the population, need assistance. It says 5.3 million people received food assistance on a monthly basis last year; 6 million were given water, hygiene and sanitation aid; and “22.8 million medical procedures were supported by humanitarian actors”.

What OCHA does not say in its publicity is that the large majority of this effort is dependent on the Assad regime’s permission.

UN officials regularly blame lack of funding for an insufficient response to need, but the failure beyond this is systematic. Almost all UN donor money — $4 billion until August 2016 — has been channelled through Damascus, with a large portion ending up in the pockets of Bashar al-Assad and his cronies. The regime dictates where UN aid goes. It directs with which partners the UN must work, such as the Syrian Arab Red Crescent or First Lady Asma al-Assad’s Syria Trust for Development, which staff they can hire, and how procurement contracts are set up.

In July 2014, the UN Security Council adopted Resolution 2165, allowing cross-border aid into Syria with a priority on humanitarian assistance over state sovereignty. Resolution 2249 extended the mandate in December 2018. But the authority is curbed by the UN’s choice to work out of Damascus, giving the regime leverage over operations.

The UN justifies this submission to the Assad regime, which is largely responsible for the killings, torture, siege, and displacement in Syria since 2011, by the need to retain capability for operations. However, they are walking a very fine ethical line. UN donor funds allow Assad to continue his brutal war against civilians by subsidizing his crippled budget and circumventing US and EU sanctions, with expenditure on weapons rather than food and essential goods.

Consider Syria’s national blood bank. Since the blood bank is controlled by the sanctioned Syrian Defense Ministry, it cannot procure blood products. So the UN’s World Health Organization (WHO) purchases the supplies for the Ministry that is ordering targeted airstrikes on civilian infrastructure, including hospitals and other medical facilities. In June 2016, WHO’s regional director Elizabeth Hoff was presented with a plaque by the Deputy Defense Minister for her “efforts to alleviate the unjust economic embargo on Syria”.

The lion’s share of UN aid is sent to areas controlled by the regime. Convoys rarely reach rebel-controlled areas and are subject to Assad’s approval if they embark from Damascus. Any convoy moving beyond regime-held territory must have permission from ministries and intelligence forces through “facilitation letters”. Life-saving medical equipment — surgical supplies, sterilization items, obstetric kits for midwives, kits for treating burns, dialysis sets, and critical medicines such as antibiotics, insulin, and vaccines — are usually not permitted or banned at a later stage by a practice called “deletion”. This involves the Foreign Ministry, the Health Ministry, and security personnel who control the UN/Syrian Arab Red Crescent (SARC) warehouse.

A “Compliant” World Health Organization

The WHO is not only aware about these practices but also have taken them into account as part of standard operating procedures.

On February 10, an independent human rights activist requested information on the list of items delivered by a UN/SARC convoy five days earlier to the Rukban camp near the Jordanian border, where more than 40,000 residents had been besieged by regime forces backed by Russian personnel.

WHO staffer Yahia Bouzo replied with the requested list and the unsolicited assurance that “no reduction or rejection of any medical supplies in this shipment was made by the Syrian authorities”.

The activist asked Bouzo on February 11 to elaborate on the statement with examples of medical supplies which are deleted from aid convoys as common practice.

ACTIVIST: Does [your previous statement] imply that the Syrian regime usually deletes items?

BOUZO: Yes, this was a practice in the past when there were besieged areas under the control of armed opposition groups.

ACTIVIST: Based on which assessments do they delete items?

BOUZO: Based on health authorities’ assessment.

ACTIVIST: Do they remove the most critical ones [items], I assume?

BOUZO: Mainly surgical supplies and blood products.

The exchange raises two issues. Is the WHO failing to distance from the Assad regime? Has this become so “normal” that its staff effectively acknowledge complicity in the deprivation of vital medical aid to a source unknown to the organization’s officials?

Neglecting Medical Evacuations from Rukban

The same activist obtained a UN document from the WHO’s regional director Hoff, summarizing the health care situation in the Rukban camp. The assessment, from a humanitarian aid convoy in early November, describes the absence of physicians with three makeshift clinics run by nurses and healthcare workers able to provide only simple medical services and care. More serious cases are referred to a UN clinic run by the United Nations Children’s Fund (UNICEF) across the border in Jordan. However, access is extremely limited, mainly because of rigorous security checks by Jordanian authorities.

The document describes a medical evacuation protocol to Jordan’s capital Amman or Damascus. These evacuations are coordinated and facilitated by the WHO’s partner Syrian Arab Red Crescent after approval by the regime. The return of evacuees is also dependent on regime approval, a potential violation of international humanitarian law.

Asked about the return of evacuees, WHO Health Cluster Coordinator Azret Kalmikov acknowledged the potential restriction of the freedom of movement of evacuees and said, “We will push for this [not to occur].” He did not elaborate further on what this means in practice.

A statement from Hoff said the regime’s Foreign Ministry considers the requests for evacuations and follow-up by SARC. However, without the regime’s permission, “Nothing can be done…and we do the maximum we can’.

Three evacuations under the protocol took place between December 2018 and March 2019, two to Amman and one to Damascus. As per a statement by Hoff, medical evacuations are not under their responsibility. Three other medical cases — one of which was the emergency of a suspected deep vein thrombosis — were reported to Elizabeth Hoff on January 2. She referred these patients to the UN/SARC’s medical point within Rukban, and promised to advocate evacuations with the regime and the SARC. But, according to an e-mail on February 10, the regime Foreign Ministry raised concerns over the selection process for the evacuees. No action was taken while UN/SARC staff was present in Rukban during the second aid convoy, which arrived on February 5 and the fate of the patients is unknown.

Other than the three confirmed evacuations, arranged with close oversight by activists, there are no known transfers to either Amman or Damascus.

Even Closer to the Regime?

Concern has been raised further by UN plans to move more aid operations to Damascus.

Mark Lowcock, the UN Undersecretary-General who heads the Office for Coordination of Humanitarian Affairs, announced the plans in a closed-door meeting in early April.

Syria Daily, May 4: Concern as UN Quietly Plans Move of Aid Operations to Damascus

Since early 2015, aid operations for much of Syria have been run both from Damascus and in Jordan’s capital of Amman, with officials in both locations given equal decision-making authority. But now the UN staff will be centered in the Syrian capital.

The UN also has an office in Gazientep, Turkey, for aid distribution, but its head is subordinate to the Amman coordinator who would be removed under the OCHA plan.

The “Whole of Syria” approach had attempted to ensure deliveries not only to regime-held areas but also to opposition territory, with an estimated 4.5 million of about 17 million people still living in Syria.

UN staff, aid workers, and activists reacted with concern to the proposed changes, saying the effect would be to undermine cross-border aid deliveries from Iraq, Turkey, and Jordan.

“[Assad] did not win yet, but [this] is helping him to finalize [victory]. It is changing the system to support him,” one aid worker noted.

A Meeting in Geneva

But these worries did not seem to affect WHO Director-General Tedros Adhanom Ghebreyesus as he met the regime’s Health Minister Nizar Yazigi in Geneva last week.

Instead of considering sieges and the regime’s ongoing refusal to allow aid to opposition areas, the meeting was an opportunity for Yazigi to proclaim “full medical coverage in Syria amid the challenges of the destruction of hospitals and medical centers as a result of the war and economic sanctions”.

(Yazigi did not mention that almost all the “destruction of hospitals and medical centers”, including 20 in opposition-held northwest Syria in the past month, were by pro-Assad attacks. There is no record that Ghebreyesus corrected him.)

The Health Minister pushed the line that sanctions should be lifted on the Assad regime, as they are “hindering the delivery of certain medicines and medical equipment”.

According to Syrian State media, “Ghebreyesus expressed appreciation of the achievements of the Syrian Health Ministry, particularly its success in eradicating polio. The WHO is continuing to provide all requirements of the health sector in Syria.”

The WHO’s Twitter outlet echoed the Assad regime line, presenting a meeting between its regional director for Syria, Ahmed al-Mandhari, and Health Minister Yazigi.