The Humanitarian Crisis in Syria

In March of 2011, peaceful anti-government protests began in parts of Syria, inspired by the Arab Spring, a series of rebellions that were spreading across the Middle East. However, these protests were quickly and violently shut down during a government crackdown led by President Bashar al Assad. This restraint by the government promptly led to a full-blown civil war across the country. After just two months into this civil war, refugee camps prepared to open across the border in Turkey to provide relief for Syrian people who were escaping this national crisis (The UN Refugee Agency, 2019). Syrians began fleeing across the region and into other neighboring countries including Lebanon, Jordan, Iraq, and even Egypt. They would find refuge in anything from temporary shelters or tents to parks if camps weren’t established. By 2012, Lebanon became the major destination for Syrian refugees, with Jordan close behind after having opened a refugee camp, Za’atari near the border, which was able to house tens of thousands of refugees (Staff, 2019). While this camp was only meant to be temporary, it still remains open to this day.

To make matters worse for the people of Syria, it was found by the U.N.Human Rights Council that the government of Syria was committing war crimes by disobeying international humanitarian law and targeting non-violent civilians. In 2013, war crimes expanded to include confirmed chemical attacks, which is a direct violation of the Geneva Protocol, which bans the use of chemical and biological weapons in armed conflict (Staff, 2019). The number of refugees continued to rise that year, with the UN Refugee Agency confirming that more than one million people had left Syria by March (The UN Refugee Agency, 2019). As the quantity of refugees continued to rise, so did that of internally-displaced people (IDPs), who were people fleeing their homes, but remaining within the country. Both groups required an extreme amount of humanitarian assistance in terms of shelter, food insecurity, medical emergencies, protection, etc. The regime under Assad carried on with violating international laws, by mistreating people and restricting freedoms, in order to attempt and break the opposition forces. At the time, Assad ordered control over who and what humanitarian assistance would be allowed into the country, essentially denying aid to those in need, and since Syria had no official non-governmental organizations (NGOs), it became increasingly difficult to help those being neglected or mistreated by their government. Soon, the World Food Programme (WFP) was given access to the country and approval to work with local partners (Pollock & Tabler, 2013).

The year 2014 saw a continued increase in the number of camps and refugees. An additional camp opened in Jordan, it was estimated that over one million refugees were residing in Lebanon alone, and almost 100,000 Syrians had reached Europe for refuge (Staff, 2019). Whether it was a neighboring Middle Eastern country, or one all the way in Europe, the influx of refugees into each of these regions was causing a major strain on each of the nation’s social, political, and economic systems. The crises, now involving many other countries, required more than the typical life-saving humanitarian aid following a disaster, this emergency demanded vigorous economic development in order to help the host countries manage (Spiegel et al., 2014). The conflict, despite causing the need for increased medical services, made it progressively more difficult to obtain. Hostilities added stress on the medical facilities, often wrecking them and obstructing the acquisition of resources, as well as outright targeting health care workers. Considering that Syria was a fast-growing lower-middle-income country before war began, their epidemiological profile was much more similar to that of the United States or Europe than Sub-Saharan Africa, for example, which meant that in addition to the already diminished access to the health systems, it would be much more expensive to respond to the issues (Spiegel et al., 2014).

The following year, complications increased; multiple European countries were closing off their borders to refugees, Greece, on the other hand, was accepting thousands of refugees daily, UN agencies and NGOs were experiencing a funding shortage, and the infamous photograph of the 2-year-old Syrian boy, Alan Kurdi, washed up on the shores of Turkey astonished everyone (Staff, 2019). The crisis was continuing to escalate and with each day, gaining more attention from the world. With more than three million people having found refuge in other countries over the four years of conflict and now two-thirds of the population requiring urgent assistance, it became known as the worst humanitarian crisis of our time (Mercy Corps, 2015). Warfare persists for the next few years and doesn’t appear to have an end in sight. In 2016, a car bomb in Jordan leaves tens of thousands of Syrian refugees trapped when the border is closed, more civilians are caught in the crossfire between the government and the rebels that fails to conclude conflict, and in 2017, almost sixty more people are killed in what is believed to be a nerve gas attack (Staff, 2019).

International agreements for the de-escalation of the conflict in Syria are made, yet neglected. Humanitarian assistance is becoming constrained in terms of figures and contact with refugees who are in inaccessible areas. The Syrian Observatory for Human Rights (SOHR) in the UK estimated in 2018 that the death toll of the Syrian Civil War was more than 500,000 (Roth, 2019). In attempts to assist in the progress of cease-fire, Russia and Syria called for refugees to return home. The alliance between these two country’s militaries continued to disregard the basic human rights of the people and performed attacks on more than twenty-five health care facilities, eleven schools, and many more civilian residencies (Roth, 2019). In 2019, conflicts in the northwest resulted in additional destroyed health care facilities and over 100,000 displaced people (Staff, 2019). Healthcare centers, hospitals, schools, as well as water and sanitation systems continue to be destroyed in the war, making it essentially impossible for civilians to continue on with their lives if they’re not targeted or killed in crossfires. With war raging on, the displacement crisis escalated, and as a result, neighboring countries were closing their borders to any more Syrians who were attempting to seek asylum from the violence within their country. By the latter half of 2018, Lebanon had registered more than one million refugees, Turkey had registered almost 3.6 million, Jordan had registered almost 700,000, and the United States granted Temporary Protected Status (TPS) to only the 7,000 Syrians who were already living in the U.S., but no new refugees (Roth, 2019).

Most recently, in the progression of conflict, a military strike occurred by Turkey on the Syrian-Iraqi border in the northeast in order to prevent the Kurdish forces from strengthening this area (Coskun & Butler, 2019). This came as a result of U.S. troops being withdrawn from the region by President Donald Trump. This operation consequently leaves U.S.-allied Kurdish forces vulnerable to the attacks by the Turkish Armed Forces, which occurred just this month.

Understanding the severity of the conflict occurring within - and outside of - Syria is crucial in determining solutions to end this almost nine-year civil war. It has become much greater than a humanitarian issue, with governments disobeying international humanitarian law and inadequacy of the international community to be able to intervene. Not only are infrastructure issues, such as roads, water, and sanitation, tremendous within the country, but also in the countries that are hosting all of the refugees from Syria. The extent and intricacy of the conflict, along with the lack of access make for an incredibly unique situation (Spiegel et al., 2014).

Health Care in Emergency Response Situations

It is under international humanitarian law that health care is provided and respected, even in times of armed conflict. Refugees have a right to satisfactory services and should be given comparable services to those given to host country nationals. However, there is no single model as to how medical services should be provided, whether in a refugee settlement or in the field. This design is dependent upon the context of disaster, the epidemiology, and the resources available. Assessing the situation and health needs of people who have been displaced by disaster or conflict is an extensive challenge, especially in the world today. This initial assessment, however, is fundamental and must be done by experts.

What needs to be considered in the implementation of health services is whether it is a long-term or short-term situation, as well as, the recommendations for the surveillance, control, and prevention of existing or hypothetical diseases. Health risk factors in the specific region are essential in evaluating the health status of the refugee population (UNHCR, 2007). Often times, as a result of forced migration, there are exceptionally high rates of mortality, morbidity, and malnutrition, with the most severe figures occurring during the acute emergency phase, or approximately the first week (CDC, 1992). This is, in part, due to the obstacles that these populations are exposed to in an emergency situation: a lack of proper shelter, safe water and sanitation, food supplies, and overcrowding, disease, malnutrition, hunger, fatigue, physical violence, and grief (UNHCR, 2007). Despite improved and timely approaches to establishing health care systems, these rates still remain high in these situations. Investigating the health status of migrating populations is often very difficult. Mortality rates, for example, may be inaccurate as a result of a poor representative sample, families not reporting all of the deaths, incorrect estimates of the affected population, etc. (Toole & Waldman, 1997). High mortality rates in refugee populations appear to be inevitable, due to patterns and past experiences, so the primary concern when establishing the health care systems is to avoid increased mortality and morbidity. To accomplish this, the immediate focus should be given to preventing and controlling the central causes of the high mortality rates - malaria, acute respiratory infections, measles, malnutrition, and diarrhoeal diseases - and the causes of the high morbidity rates - tuberculosis, meningitis, vector-borne diseases, STIs, and HIV/AIDS (UNHCR, 2007). Special attention needs to be given to those who are more susceptible to these diseases - children, elderly, sick, pregnant women - as well as additional attention to the reproductive health of women.

Typically, in response to a crisis, the international community will respond quickly but ineffectively, providing inadequately trained staff and not focusing on a primary health care (PHC) approach, which includes preventative programs, promoting the involvement of the refugee community in the services, efficient coordination, and examination of the population (CDC, 1992). According to the UN Refugee Agency, an adequate PHC will include the promotion of proper nutrition, safe supply of water, basic sanitation, reproductive and childcare, disease treatment, immunizations, prevention and control of diseases, and health education (UNHCR, 2007). Advancing the basic health education of the refugees, and training them as health care workers assures continual care when humanitarian organizations are no longer required (UNHCR, 2007). This comprehensive approach to health care systems is not only more effective but also sustainable in the long-term and for both the refugee community and the host country.

Another important program to implement in the foundation of a health system is an early warning system. This system is a form of disease surveillance and can theoretically anticipate signs of natural disaster or conflict and thus limit the effects. The addition of a natural disaster or social instability will further add stress to the situation and allow for a more vulnerable population. The health system in a refugee population should be established in a four-tier model including a referral hospital, which offers specialized services; a central health facility, which offers 24-hour services, deals with common priority diseases, and serves between 10-30,000 refugees; a peripheral health facility, which offers a basic level of care and serves 3-5,000 refugees; and finally, home-visitors, who serve about 500-1,000 refugees each and act as an aid in surveillance (MSF, 1997).

Before the commencement of the civil war in 2011, Syria was in the process of moving from a country with the prevalence of communicable to non-communicable diseases, something that’s more commonplace in developed countries. Since war has begun, however, Syria has faced a digression within the field of healthcare. Much of its critical infrastructure has been destroyed, water and sanitation sources deteriorated, services disrupted, and access restricted due to security factors (Kherallah et al., 2012).

Due to the large displacement of Syrian refugees and increased need for medical care, Medicins Sans Frontieres (MSF) or Doctors Without Borders continually researched what the most prevalent needs of the populations were and provided that assistance, often in hospitals, health care centers, and displacement camps (MSF, 2018). Examining each individual population on the care that they need will guarantee that time and resources are not wasted, and appropriate care can be provided. Among other services, MSF delivered maternal health care, care for non-communicable diseases, relief items, enhanced water and sanitation health (WASH) systems, and vaccination programs.

Based on a systematic review of the primary health needs of Syrian refugees in neighboring countries, such as Lebanon, Jordan, Turkey, Iraq, and the internally displaced in Syria, it was found that women’s health and mental health were the greatest health needs required in the region, specifically in Lebanon and Turkey, because they are receiving the least amount of attention (Arnaout et al., 2019). Mental health, particularly in terms of PTSD and trauma, is often overlooked in humanitarian crises and therefore, adequate aid is not provided. The analysis also found that non-communicable diseases were the most popular health needs in Jordan (Arnaout et al., 2019). Another major issue, as mentioned earlier in this report, is the lack of properly trained and available health care workers. There is an urgency for a skilled workforce who have an awareness of the issues and the knowledge to assist. On March 5, 2017, Syrian refugees in Jordan were permitted to register with the UNHCR to receive health care services within the Ministry of Health (MOH), PHCs, and hospitals free of charge (UNHCR, 2017). The need for essential health services for the vulnerable refugees was noticed and this pass was developed to encourage the people to use the services. However, in November of 2014, this arrangement was removed and the refugees were then required to pay for the health services, but at a discounted price compared to what Jordan nationals were paying for the services (UNHCR, 2017).

The health and well-being of civilians, including refugees, is a basic human right that needs to be established at the onset of disaster or conflict. Each humanitarian operation will demand a different approach to the exact services required, however, regardless of the distinct needs of the population, organizations should attempt to the best of their ability to provide those specific needs. Internally displaced persons and refugees of any country are forced to endure inhumane circumstances as it is. Guaranteeing the establishment of sufficient health care services and resources is essential during humanitarian relief operations where the support and relief of suffering of these people is the forefront of the mission.

Safety and Security in Humanitarian Crises

Safety and security has and always will be an extensive issue when it comes to humanitarian crises. In times of disaster or conflict, safety is a concern to the non-violent civilians of the country in question, and more recently, the humanitarian relief workers who are making an effort to provide aid for these civilians. It is under international humanitarian law that these relief workers be protected and salvaged from armed conflict, however, the safety of these workers is becoming increasingly questionable and difficult to manage as many are becoming targets of violence.

In August of 2003, the UN High Commissioner for Refugees and envoy in Iraq, Sergio Vieira de Mello, was killed in an attack on humanitarian workers that occurred just outside the UN headquarters in Baghdad, along with at least a dozen other people (Kessler, 2003). The attack, a car bomb that was detonated at the compound where more than 300 United Nations staff members’ work, was targeting the United Nations Assistance Mission in Iraq (UNAMI). The political mission was established earlier that same year and was intended to protect the Iraqi citizens and their human rights, following the armed conflict and violence that extended across the nation (OHCHR, 2003). Attacks on workers such as this one directly affects the progress of the humanitarian mission and therefore the sufficiency of and time in which aid can be given to the civilians who are in need.

Despite humanitarian workers selflessly operating in inhospitable regions for decades, and even centuries, it has only become recently that such workers are facing threats to their activities and livelihoods. Provisions must be taken by the humanitarian workers themselves as well as the host government in order to ensure the safety of the people who are genuinely attempting to alleviate the pain and suffering of those in need. A review of security standards currently in place would benefit from being reviewed and revised to maximize the safety of all people.

The WFP outlines in their Emergency Field Operations Handbook a list of personal security efforts to be considered as a humanitarian relief worker. The list includes actions such as gaining knowledge and awareness of the UN security plan of the country, security briefings prior to entering the country, and informing others, specifically the security officer, of travel plans (WFP, 2002). In any situation in which someone is put in a threatening or hostile environment, having an arranged plan and simply being cautious and aware of their surroundings is fundamental in assuring their own safety.

Aside from the individual worker, the responsibility of safety also lies in the hands of the host government. It is important that each office have distinct security and medical evacuation plans. Within each country, there is a Designated Official (DO), appointed by the UN agency, who is in charge of the security arrangements and liable for the lives of UN workers (UNHCR, 2007). The DO should create the security and evacuation plans that are essential within each country, as well as a Security Management Team (SMT), which assists the DO in their duties. The security plan devised by the DO should consist of five phases - precautionary, restricted movement, relocation, emergency operations, and evacuation - with specific guidance and instruction for actions in each phase (UNHCR, 2007). This approach of breaking up actions into phases makes for a clearer picture of what is going on in the country and what conditions are like.

In addition to the protection of humanitarian relief workers, it is evident and crucial to provide protection for the civilians. The number one priority for ensuring the safety of the innocent civilians who have been forced to flee is to provide a secure location, where the people feel that they are free from harm. Many organizations, including The International Committee of the Red Cross (ICRC), the United Nations High Commissioner for Refugees (UNHCR), and the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), work to arrange this necessity (USAID, 1998). Along with UN agencies and humanitarian organizations, foreign military forces have historically been seen and utilized as significant partners in responses to complex emergencies and providing security to civilians. An example of this occurred in northern Iraq following the Gulf War, when the U.S. military provided relief efforts to the Kurdish people who became displaced as a result of conflict (Sharp et al., 2001). In this situation, the Kurds had rebelled against Saddam Hussein, but ultimately failed, and more than one million people were then forced to flee to western Iran. Consequently, they experienced typical issues that arise for displaced populations: lack of shelter, food, safe water, and an outbreak of disease. In a mission called Operation Provide Comfort, U.S. forces combined with humanitarian relief organizations to support the refugees in terms of security and supplies, the first time a joint-mission like this was seen. Thanks to the efforts of the military, mortality rates declined and many Kurds were able to return home (Sharp et al., 2001).

The struggle when deploying military forces into a region where assistance is essential is making sure that they stay in their roles while remaining neutral and impartial. The military should be exclusively providing protection and ensuring peace is maintained, not engaging in the work of humanitarian agencies such as providing vaccinations or other basic or disease-related health care services. They should be adequately “trained, equipped, and supplied for disaster relief and humanitarian assistance” (Sharp et al., 2001). The involvement of the military in humanitarian relief conditions is dependent upon compelling political and public success, but must still remain objective. Under the Weinberger Doctrine, there must be detailed military and political intentions before the forces will be deployed for intervention (Sharp et al., 2001). It is imperative that foreign militaries in this situation coordinate and communicate with each other, as well as NGOs and other humanitarian relief organizations that they will be working with indefinitely.

The latest and most serious concerns to the safety of Syrians, in the last eight years of conflict, is occurring right now. Following President Donald Trump’s instruction to pull U.S. troops out of Syria, Turkish President Recep Tayyip Erdoğan ordered his military forces to attack the Kurdish people in north-east Syria on October 9, 2019. For many years, the Kurds have been a strong ally to the U.S., assisting in the fight against ISIS, often doing most of the fighting and consequently, dying. After this move by the U.S. in which the Kurds must now fend for themselves, they no longer trust the U.S. The only solace that President Trump offered was to call the President of Turkey, as well as, sending Vice President Mike Pence to Turkey to negotiate and request a ceasefire of the attacks. After this meeting took place, Turkey agreed to immediately put a pause to the attacks for 120 hours in order to allow the U.S. to assist the progress of removing YPG (Kurdish) forces from this region of Syria (The White House, 2019). Once this has been accomplished, Turkey has agreed to permanently ceasefire. This advancement will at least temporarily relieve the uninvolved civilians from enduring any additional harm.

In humanitarian crises, the safety and security of unarmed civilians and humanitarian relief workers is critical and compulsory under international humanitarian law. A violation of this law is considered a war crime, but it is still frequently observed in emergency situations across the world. Humanitarian organizations, local governments, and foreign militaries must work together to ensure the upholding of this legislation. Lowering the risk of violence to innocent and unarmed populations allows for increased and improved delivery of additional services.

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