In the predominantly Kurdish-controlled region of north-east Syria, healthcare capacity is low even by Syrian standards. A recent report by the World Health Organisation (WHO) described the region as ‘one of the most under-served in Syria today with the number of health facilities, hospital beds and health care workers well below accepted standards’. Less than 10% of public healthcare facilities and just two of 11 public hospitals are fully functional, and no district meets the emergency threshold of at least 10 beds per 10,000 people. Health experts have warned that the region has the capacity to deal with around 500 Covid-19 cases, at best. It is difficult to imagine conditions more vulnerable to an outbreak of the virus.
North-east Syria is home to 780,000 internally displaced people, forced to flee their homes over almost a decade of conflict. Around 225,000 live in ‘last resort sites’, including camps and informal settlements, with inadequate basic services in healthcare, clean water and sanitation. The largest camp, Al-Hol, holds 65,000 people, with a population density of 37,570 per square kilometre. By contrast, New York State has a population density of 159 people per square kilometre – and has seen more than 24,000 Covid-19 deaths. Aid agencies working in the camp say there is ‘absolutely no way for people to practice social distancing’.
Covid-19 in north-east Syria
As of early June, the Syrian Government had reported 141 Covid-19 cases from government-held areas, and an additional six cases – including one fatality – had been reported from the north-east. Due to limited testing capacity, actual numbers are likely to be far higher. Until recently, local authorities in the north-east had to send their samples to Damascus for testing, with results coming back two weeks later. The first positive test result was only received by the authorities in north-east Syria 11 days after the patient’s death.
In mid-April, the Northeast Syria Forum warned that ‘the risk of COVID-19 in Northeast Syria is considered very high’. WHO has warned that ‘it is just a matter of time’ before the outbreak escalates. Aid agencies fear that, when that escalation does occur, the lack of basic healthcare and hygiene and sanitation facilities will make the virus almost impossible to contain. In one recent assessment, 18% of communities surveyed said that less than half of their people had somewhere to wash their hands, and nearly half the communities surveyed said that most households couldn’t afford soap.
Humanitarian access constraints
Aid agencies struggling to prepare for Covid-19 face government restrictions on the shipment of medical equipment, supplies and personnel into north-east Syria. Agencies can request permission to transport supplies to the north-east, but the government typically takes 3–4 months to respond. In the past couple of weeks WHO has been able to transport medical supplies to north-east Syria by road from Damascus, but these were the first such deliveries in two years. Access is easiest from Iraq, but the Syrian government does not permit it, and the UN’s position is that, under international law, humanitarian assistance cannot be provided without the consent of the host state.
In 2014, the UN Security Council passed a resolution authorising aid agencies to enter north-east Syria via the Yarubiyah border crossing from Iraq – and to enter other parts of Syria via designated border crossings from Jordan and Turkey – without the government’s consent. WHO used this authorisation in 2019 to ship 210 tons of medical treatments and other medical equipment into the north-east. NGOs have also relied heavily on the Yarubiyah crossing. According to WHO, international NGOs operate 58 primary health centres, 37 mobile health units and 13 hospitals in north-east Syria, most of them dependent on cross-border shipments of medicines and supplies from Iraq. Altogether, some 2.1 million people in the north-east have received medical services and supplies shipped across the border.
Between 2014 and 2019, the UN Security Council renewed its authorisation of the border crossings into Syria annually. This changed in December 2019, when Russia and China vetoed a resolution that would have once again authorised all four border crossings. After heated negotiation, in January this year the Security Council re-authorised crossings into north-west Syria from Turkey, but not the Yarubiyah crossing. That brought an abrupt end to the UN’s – and most significantly WHO’s – cross-border support for north-east Syria.
In February, the UN Secretary-General warned that, due to the closure of the Yarubiyah crossing, by May there would likely be ‘gaps in basic medicines in medical facilities previously supplied by the United Nations cross-border operation’, limiting ‘the ability of medical providers to deliver a broad range of critical medical treatments to people in need’. That was before Covid-19.
NGOs continue to operate in north-east Syria, but they lack the funds and logistical support previously provided by the UN. Human Rights Watch recently reported that the closure of the Yaribuyah crossing had left NGOs with a $40 million shortfall for operations in 2020, including $30 million for healthcare. Without a partnership with the UN , NGOs are also unable to access funding raised through the Covid-19 Global Humanitarian Response Plan and the Syria Cross-Border Humanitarian Fund.
The upshot has been that NGOs in north-east Syria have not been able to adequately prepare for Covid-19, and they lack the resources and capacity they would likely require to respond to an escalation of the outbreak.
What the UN Security Council should do
In a draft paper circulated to the Security Council at the end of April, WHO warned that Covid-19 could have a ‘truly catastrophic’ impact in Syria, and appealed for the Yarubiyah crossing to be re-opened. That was deleted from the draft, reportedly at Russia’s insistence. The final version of the paper circulated to the Council said that ’the cross-line option … will not be sufficient to support an effective response to COVID-19’, and that ‘new options are needed to fill the significant gaps and to continue the humanitarian assistance previously delivered through Yarubiyah’. Given the circumstances, the Security Council should immediately pass a resolution re-authorising the use of the Yaribiyah crossing. Preventing aid agencies from containing the spread of the pandemic in a country with such low capacity to respond is surely difficult for any member of the Security Council to justify.
And if the Security Council fails?
International humanitarian law states that governments must not arbitrarily withhold consent for humanitarian assistance; international human rights law states that governments have an obligation to facilitate humanitarian assistance, if failing to do so would deny the population ‘minimum essential levels’ of food, water and healthcare. There is little question that the Syrian government has acted illegally in not more readily consenting to and facilitating humanitarian assistance in north-east Syria. Some argue that, if governments illegally withhold consent, then humanitarian agencies, including the UN, can go ahead and provide assistance anyway.
There are also many international lawyers who argue that a state’s sovereignty does not encompass the right to deny its people access to their basic rights. According to this view, entering a country without permission for the specific purpose of enabling people to access their rights, for example by providing healthcare, does not interfere with state sovereignty, and as such does not violate international law. Finally, even if one accepts the view that entering Syria without consent is illegal, international law recognises a defence of ‘necessity’, allowing an international organisation, such as the UN, to do something that might otherwise be illegal – like entering a state’s territory without consent.
In the last few months, governments around the world have imposed unprecedented restrictions on people’s basic liberties due to the absolute necessity of containing the spread of the virus. These measures, some of which would have previously been seen as human rights violations, have largely been accepted as justified. Isn’t sending medical supplies and equipment to north-east Syria to enable humanitarian agencies to prevent, treat and respond to an outbreak of Covid-19 in one of the world’s most vulnerable regions similarly justifiable?
Rebecca Barber is a lawyer, independent consultant, and PhD scholar with the TC Beirne School of Law and Asia Pacific Centre for the Responsibility to Protect, University of Queensland.