Regime-held areas: Securitized and incompetent response

Throughout the war, long-time problems that have plagued Syria’s health system were exacerbated, namely, corruption, profiteering, appointments based on loyalty, and geographic disparities in the quality of care. Thus, the health care system in regime-held Syria reflects larger trends in service provision in the country. The unchecked corruption and impunity afforded to state officials manifests in a widespread phenomenon of theft of medical supplies from state hospitals by staff and demands that patients pay for medical examinations. Even before the war, areas outside of the cities of Damascus, Aleppo, Tartous, and Latakia had limited access to quality health care.

During the war, provision of all services, including health care, became even more closely linked to perceived loyalty. The Syrian regime and Russia pummeled areas that fell out of regime control, such as southern Syria, eastern Ghouta, and Homs, and specifically targeted medical facilities and personnel. Because the regime targets medical workers for arrest, during the surrender deals imposed by the regime — framed as “reconciliation” agreements — a large share of the medical staff chose to be displaced to the rebel-held north rather than remain under regime control. Since the regime’s reconquest of these areas, health services have largely not been restored and hospitals were not rebuilt. “During the days of the opposition services were better than now,” said Mohammad, an employee of the Ministry of Electricity living in Harasta, which was reconquered by the Syrian Army in 2018 after a five-year siege. “Despite the lack of medical equipment and drugs, at least the doctors and nurses tried to do their best to provide services to all. Now care in regime hospitals is based on connections and favoritism.”

The Assad regime’s management of the COVID-19 crisis shows that it continues to prioritize its own extremely parochial, security-centric interests in ways that blatantly undermine public health. Multiple decisions made by the regime have already hindered the ability of medical professionals to tackle the crisis and of citizens to protect themselves from the spread of the virus. These decisions include not shutting down flights from Iran, an epicenter of the pandemic; continuing to allow pro-Iranian militiamen and Iranian advisers to enter Syria from Iraq and Lebanon and interact with Syrian soldiers, militiamen, and scientists; granting the secret police a prominent role in managing the crisis, deterring civilians and particularly regime opponents from seeking medical assistance or informing on suspected COVID-19 cases; refusing to allow the WHO to establish a lab with a PCR machine that can conduct testing for the SARS-CoV2 virus in northeast Syria, significantly hindering the ability to quickly trace cases and isolate those who have come into contact with them; not disclosing crucial information about identified COVID-19 cases to allow communities to protect themselves; and creating public messaging that will likely deter individuals from reporting on suspected cases or asking to be tested themselves.

Other steps taken by the regime appear to stem from incompetence. The Ministry of Health did not carry out tests for a whole month after receiving PCR machines from the WHO in mid-February; individuals whose relatives are suspected of becoming infected are not notified about the test results for days, during which they continue to move around and potentially spread the virus; the government imposed lockdown measures that increase congestion in the streets; the Ministry of Health is still not testing individuals who have come in contact with confirmed COVID-19 cases; the government is not providing clear information about how individuals who believe they are suffering from the virus should get tested; and the Ministry of Health has not supplied medical personnel with personal protective equipment (PPE), informed them about COVID-19 symptoms, or trained them on IPC measures.

Damascus has taken a number of steps to reduce the spread of the virus, including closing schools and universities, ending communal prayers in mosques, ordering the closing of shops, reducing the work hours of state employees, ending movement between governorates, and instituting a curfew from 6pm until 6am. As a result of the latter, however, food markets and distribution centers for subsidized food are overcrowded during their hours of operation.

The ever-present secret police

Similar to the handling of the crisis in China and Iran, rather than trying to get ahead of the situation, Damascus has sought to keep it invisible. The regime’s knee-jerk reaction to the outbreak was to try to control what information got out. The various branches of the mukhabarat, the core of the regime’s ruling apparatus, were deployed to control the information environment. Outside of hospitals, the mukhabarat arrested individuals who spread rumors on social media about possible COVID-19 cases and even when they communicated accurate information. When one resident of the Damascus countryside informed his colleagues through a WhatsApp group that another colleague was sick, he was arrested, even though such information could encourage individuals to get tested and or self-isolate to prevent the spread of the virus.

Doctors working in community clinics described receiving visits from the mukhabarat after daring to send patients suspected of COVID-19 for further tests in Damascus. Daoud, a doctor who runs a private clinic in an area bordering Lebanon, recounted receiving a patient who entered Syria through an irregular border crossing from Lebanon. The patient presented signs of COVID-19 and Daoud directed him to go for testing in Damascus. “The mukhabarat came to visit me and told me to inform them when I receive suspected COVID-19 cases. I was ordered not to direct cases on my own, or they’ll shut down my clinic. They threatened me to disclose the name and details of the patient.”

Inside hospitals, the secret police have further tightened their grip over the medical staff. Following the start of the Syrian uprising in 2011, mukhabarat officers were deployed to all major hospitals and are assigned their own office. Doctors described a climate of fear, as fellow doctors, nurses, and even cleaning staff inform on one another to the secret police. “Our role as doctors is merely to execute the orders of the mukhabarat,” said Fatima, a young doctor working at a central state-run hospital in Damascus. “They intervene in the decisions of the director of the hospital and the head physician. They intervene even on issues of who gets x-rays and other tests.”

The outbreak of COVID-19 has further bolstered the influence of the mukhabarat inside hospitals. “They’re behaving in the hospital as if we’re a branch of the secret police. Weird things are happening at the hospital,” said Hassan, the doctor working at a major hospital in Damascus. Initially, he reports, when the regime continued to insist that Syria was free of COVID-19 cases, the mukhabarat warned the doctors to avoid alerting anyone about possible cases and register those who appeared to have died of COVID-19 as dying from pneumonia. After cases started being reported, “they couldn’t say anymore that there are no cases but the secrecy remains. There is a special team taking care of the COVID patients and suspected COVID patients. The other staff are not allowed to learn any information about them. The names of the patients are unknown; we can’t enter their wards.”

The securitized response of the Assad regime will likely have deadly consequences. The initial instinct of the regime to avoid reporting cases meant that individuals went undiagnosed and their relatives were not tested. In addition, concerns about the hospitals — from the low quality of care and the lack of cleanliness to the role of the secret police in tracking cases and enforcing home isolations, as well as unproven rumors that the secret police were killing patients — are deterring Syrians from trying to obtain care even if they feel sick. Multiple individuals interviewed in regime-held areas reported that if they suspect that they’ve been infected with COVID-19, they will avoid notifying authorities or seeking medical care unless they genuinely believe they are about to die. The regime’s practice of arresting men wanted for military service in hospitals may also deter young men from seeking treatment. Thousands of suspected regime opponents who have been able to hide out in areas the regime does not tightly control, particularly in southern Syria and rural areas, will also not dare to cross regime checkpoints in search of better medical care, only available in major cities.

Secrecy and paranoia

The regime has also imposed quarantines on specific towns and buildings. Damascus closed off movement from the towns of Mneen, after a resident died of COVID-19, and the Damascus suburb of Sayyida Zainab, the staging ground for multiple Shi’a militias originating in Lebanon, Iraq, and Afghanistan, as well as Iranian advisers. The health authorities did not provide residents of these towns with information about the number of cases discovered there. In Mneen, it was the family of the resident who passed away that publicly confirmed she had died of COVID-19. They were unable to alert the community until a week after her hospitalization because they were not informed that she had tested positive for COVID then. In Sayyida Zainab, the regime did not provide any information about the existence of cases, claiming the area was quarantined due to its population density, while other densely populated neighborhoods in Syria have not been placed under lockdown. In addition, the mukhabarat sealed off buildings in several towns, including Douma, Qudsiya, and Sayyida Zainab, without giving any explanations to the community. Dr. Daoud reports that the mukhabarat placed the family of a suspected patient in quarantine in their home for 20 days “but they did not test whether his relatives have the virus.”

The regime’s paranoia and efforts to prevent reporting on the spread of the virus may also stem from the perceived and actual role of foreign Shi’a militiamen and Iranian advisers in doing so. Rumors spread inside Syrian Army units working with Iranian advisers or near Iraqi and Lebanese militiamen in Palmyra and the Idlib frontlines that soldiers contracted the virus from the foreign Shi’a fighters. According to a young Damascene man who serves in the Military Research Center in Jamraya as a chemist, two of his colleagues were quarantined in Qudsiya and Sayyida Zainab with their families, after contracting the virus from an Iranian adviser working with them in a facility in Homs Governorate that manufactures long-range missiles. He himself is worried. Several of the center’s engineers and experts recently returned from training in Iran. Most of them are from the coast and were placed in quarantine there after returning, but only after coming in contact with some of the center’s other employees.

All doctors interviewed in regime-held areas doubted the ability of the health sector to cope with the pandemic due to the lack of professional staff capable of dealing with complicated cases, the sector’s poor and corrupt management, and the widespread lack of equipment. They are also worried about being exposed to the virus due to the shortage of protective gear. “We have nothing to protect ourselves,” reported Hassan, working in Damascus. He said that “the medical staff, hesitantly, asked [the administration] for gloves, protective gear, and the response was that ‘we are in a siege, the U.S. and Israel are to blame. These are the means we have at our disposal.’” Corruption is at play here too: “A nurse distributes surgical masks, not N95 [respirator masks], and those with good ties with her get masks and others don’t. I had to buy my own mask and alcohol for exorbitant prices” due to price gouging.

The regime’s dungeons

The most vulnerable population in regime-held areas to COVID-19 are prisoners, especially the tens of thousands of political prisoners who are held in particularly harsh conditions amid extreme overcrowding. Detainees are starved, tortured to death, and denied medical care. Ali, who was detained for seven and a half years for attempting to defect from military service, was held in the notorious Sednaya prison for three years and released in late 2019. “Diseases are incredibly common among the detainees, and particularly asthma, tuberculosis, scabies, and hepatitis.” Detainees largely avoid going to the doctor because “there are guards at the doctor who beat you up so that the detainee doesn’t ask again to be taken to the doctor.”

Following the spread of the virus, guards in prisons holding political detainees began donning masks and gloves. “They wear the same mask all day and it becomes filthy,” reported Hammoud, who was released from detention during the first week of April. Hammoud is a former rebel who decided to remain in his town near Damascus after the regime reconquered it and underwent the bureaucratic process of “settling his status” with the regime. In a pattern repeated across areas that went through the so-called reconciliation process, he was arrested in 2019 for belonging to a terrorist group.

In March, Hammoud and his cellmates in the Damascus prison were taken out of their cells. “We were gathered in large courtyards, ordered to strip naked, and sprayed with Povidone diluted with water.” Povidone-iodine is used to sterilize wounds and can in no way disinfect or cure a person of coronavirus. While the interrogators start donning gloves and masks, they did not stop the torture, further crippling the ability of the detainees to survive the pandemic and detention. “They also sterilized the rooms, but there is no medicine available other than aspirin. Many diseases spread in the small detention cells, where over 200 people are held together,” he reported. Sick detainees were taken out for medical treatment, but never received any medicine and were returned to the cell to infect others. Detainees often died. Even without the pandemic, “in the normal state of detainees, with our scrawny bodies, the beatings, the non-stop torture, we can’t resist illnesses, especially since we are not fed enough — usually one small piece of bread per day.”

Sanctions

Damascus is trying to use the pandemic to gain relief from the extensive sanctions regime imposed on it, primarily by the U.S. and the EU. Despite the creation of humanitarian exemptions and general licenses for UN agencies and NGOs, Western sanctions are indirectly affecting the humanitarian sector. NGOs and the WHO are required to go through prolonged licensing processes for goods such as CT scanners, laboratory testing machines, and accessories to anesthesia machines, and struggle to bring cash into the country to pay employees. The Syrian regime has not asked for general licenses from the EU or the U.S. to import goods under the humanitarian exemptions. Instead, it is relying on Iran, China, and Russia for the import of often sub-par medical equipment and medicine. Manufacturers, banks, insurance, and shipping companies prefer to end their transactions even with humanitarian organizations linked to Syria, let alone private entities or the Syrian government, for fear of heavy penalties. The U.S., which applies the most extensive sanctions regime on Syria, should reassure companies and banks along the medical equipment supply chain that they will not be sanctioned.

The regime’s own behavior — the gross corruption, incompetence, and unequal distribution of services based on loyalty — significantly limit the impact of sanctions relief. Past experience shows that efforts to prevent the regime from diverting humanitarian assistance have consistently failed, leading to UN aid going toward supporting pro-regime militias. Countries applying sanctions should consider what concrete, measurable improvements can be gained from the regime in exchange for sanctions relief, such as the release of detainees (possibly starting with medical personnel) or a halt to arrest campaigns and the bombing of hospitals. In exchange, the EU and U.S. could offer to create a humanitarian payment channel (similar to the one established for Iran), unfreeze assets, and take additional steps that would mitigate the impact of the pandemic on Syrians.