AMMAN: In the northeastern reaches of Syria’s Kurdish-controlled territory, a months-long row between local political forces is bringing operations at the area’s largest hospital to a near-total standstill.

Central to the dispute are the two main actors in Al-Hasakah’s divided provincial capital: the Assad regime and the Self-Administration, the governing authority of Syria’s de facto autonomous Kurdish-held region.

Kurdish forces control the vast majority of Al-Hasakah city following a rout of the regime’s Syrian Arab Army (SAA) last August. The offensive reduced the Assad government’s presence from more than half of the provincial capital to a one-square-kilometer foothold of administrative and security buildings. Still, the regime maintained a degree of financial leverage over the provincial capital as it continued to pay for the city’s municipal services.

Throughout the six-year war, the Assad regime has continued to fund schools, hospitals and other services in select opposition-controlled territory. Even in Al-Hasakah city, the regime funded the National Hospital of Al-Hasakah, paying for its fuel, new medical equipment and employee salaries.

But during the August 2016 offensive, the Self-Administration’s police force—also known as the Asayish—commandeered a wing within the hospital. The Asayish raised their flag overhead and expelled government soldiers from the building. The police force made no public statement at the time, but the move was a symbolic step towards removing the regime’s presence from the Kurdish-run capital city.

Staff at the National Hospital say concerns over their continued funding emerged soon after Jayez al-Hammoud al-Moussa, the regime’s governor of Al-Hasakah, took office last October. The incoming governor threatened to decrease the hospital’s financial support unless the Asayish and other partisan security forces left the building by the start of 2017 and reinstated the Syrian national flag overhead.

The National Hospital of Al-Hasakah. Photo courtesy of ARTA FM.

When the Asayish refused to leave earlier this year, the funding cuts started. First, deliveries of dialysis supplies and laboratory equipment stopped. Soon after that, some medicine began reaching critically low levels, others ran out altogether.

When the regime cut off diesel shipments needed to run the hospital’s network of generators in late March, “the situation became intolerable,” one of the hospital’s staff members told Syria Direct on condition of anonymity.

Almost overnight, the hospital became unable to run its energy-dependent equipment. Automatic respirators stopped functioning, CT scans shut down and operating rooms closed their doors. The electricity grid’s frequent and unpredictable cutoffs kept hospital personnel from using life-saving machinery that could turn off at any moment.

Today, the regime has suspended all funding for the hospital. The Self-Administration is not meeting the city’s health care needs, and medical equipment is no longer functioning due to a shortage of fuel. National Hospital personnel tell Syria Direct that the city’s only free hospital is now experiencing a “humanitarian disaster.”

As Syria Direct reporters dug deeper into the hospital fiasco, the central question became less about why the Assad government pulled funding and more about why the Self-Administration is failing to finance local services such as the National Hospital. Sources inside the hospital tell Syria Direct that the Kurdish governing authority cannot afford to fully fund the hospital, and have instead proposed charging patients for what was previously the city’s only free healthcare option.

Currently, the Self-Administration is providing limited stopgap funding to run basic services at the National Hospital, but staff members say this is the “first time” conditions have reached such a low level.

“I hold both sides responsible for the deterioration of the situation,” one National Hospital staff member told Syria Direct. “On one side you’ve got the indifference of the Self-Administration and on the other you’ve got the [regime’s] governor, but both are the reasons for this problem.”

At its core, the National Hospital showdown is part of a broader challenge in Syria’s northeast in which the Kurdish Self-Administration is unable or unwilling to provide full public services amidst their territorial gains.

The Kurdish governing authority, for the most part, has not commented.

“There are talks right now regarding the governor’s decision and the affairs of the National Hospital,” Dr. Abir Assaf, the Self-Administration’s Minister of Health, told Syria Direct earlier this month. She declined to elaborate, saying only, “We have yet to reach a solution.”

The conflict over spheres of influence in the northeast’s provincial capital is unfolding within the confines of the hospital. Both the regime and the Self-Administration have virtually shut down a medical facility that once treated more than 2,000 patients daily in a dispute over which side can fly its flag over the building.

The unprecedented rollback in services is affecting the more than one million residents of Al-Hasakah city, particularly those who are unable to afford medical care at one of the provincial capital’s five private hospitals.

Earlier this month, two of the city’s poorer residents—both of whom suffer from kidney-related diseases—had no option other than to seek treatment at the now understaffed and ill-equipped National Hospital of Al-Hasakah. The first patient suffered from diabetes, which ultimately resulted in severe nerve damage to his feet. Doctors resorted to amputating some of his toes despite having since run out of narcotics and antibiotics.

A Kurdish protest against the Self-Administration’s PYD party in Al-Hasakah, August 2016. Photo courtesy of Anadolu Agency/Getty Images.

“In a position like that, there’s just nothing else we can do,” one National Hospital staff member told Syria Direct.

That same day, a second patient came in requiring an operation on his kidney. But with both the patient and the hospital out of money, palliative treatment was the only option. National Hosptial doctors informed the man he could manage without the required surgery.

The National Hospital of Al-Hasakah now operates at under 15 percent of its capacity compared with just one month ago. Entire departments have closed their doors, including internal medicine, gastroenterology, orthopedics and radiology.

“The National Hospital provided medical services for hundreds of thousands of Syrians from Al-Hasakah and the surrounding areas as well as approximately 125,000 displaced Syrians from other provinces,” one of the National Hospital’s medical staff told Syria Direct. “What can I say to impart just how it important it is that this hospital has stopped providing services?”

‘We’re the victims’

The National Hospital dispute comes at a time of increasing Kurdish military and political influence in the region.

Since 2014, Syria’s Kurdish-controlled territories—also known as Rojava—have tripled in size. The expansion largely comes along Syria’s northern border with Turkey and the eastern border with Iraq as Kurdish forces wrest territory from the Islamic State and capitalize on the regime’s general withdrawal from the area.

In March 2016, 200 Rojava representatives voted to form a federal system in northern Syria. The move united the three Kurdish Self-Administration-controlled cantons of Jazirah, Afrin and Kobani under a single polity, now known as the Democratic Federal System of Northern Syria.

With Rojava’s de facto autonomy and increasing political reach, Al-Hasakah residents tell Syria Direct that they expected the Self-Administration to fill the void in municipal services left behind with the departure of the Assad regime. But in the case of the National Hospital, local residents say those expectations have not been met.

Umm Mustafa, 25, was nine months pregnant when she went to the National Hospital earlier this month to give birth. The hospital administration, she says, turned her away at the door out of fear that the medical equipment might shut down midway through her caesarian section.

With no other option, Umm Mustafa went to one of the city’s private hospitals and paid SP70,000 (approx. $327) out of pocket. The unexpected amount put her painfully in debt, forced to borrow from her family members.

“What was I to do, I didn’t have any other choice,” she told Syria Direct.

“Look, I don’t care who is in charge of the National Hospital,” she said, now the mother of a girl, her first child. “All that I care about is that I am able to get the medical care that I need because like thousands of people here, I am unable to bear the burden of such high hospital costs.”

In 2014 and 2015, the Syrian Arab Army reportedly seized around 50 beds from the hospital for their guards and soldiers in the area, one of the hospital’s staff members told Syria Direct. Similarly, in 2016, the same staff member accused the Asayish of pillaging the hospital for their own use, sending medical supplies to their own frontlines, particularly during the August fighting with the regime.

“There is nothing we can do about it,” the same member of the medical team told Syria Direct.

“The average citizen doesn’t care if he’s seeing the two-star regime flag or the one-star Kurdish flag [over the hospital],” the source said. “What he cares about is that he can actually find treatment.”

An Asayish spokeswoman in the Jazira Canton, Fidan Hissi, defended the Kurdish police force’s presence within the hospital, saying “they are ensuring that the hospital can continue providing services to residents.” The Asayish, she said, “is a security force that takes its orders from the political administration, one that represents the civilian government in the Jazira canton.”

Syrian state media has not commented on the dispute beyond a brief mention earlier this month of a meeting between Al-Hasakah governor Jayez al-Hammoud al-Moussa and a delegation from the International Committee of the Red Cross regarding “the restoration of the National Hospital in the city.”

Umm Sirdar, a Hasakah city resident and mother in her fifties, has kidney disease. Before the hospital ran out of fuel in March, Umm Sirdar, who suffers from kidney failure, received free dialysis treatment three times a week. Now, she has to turn to the private sector, as her son, who lives in Germany, pays SP20,000 (approx. $93.30) for each treatment. But, even with the help of his remittances, she can only afford to receive one dialysis session per week.

“It always seems that we’re the victims of this perpetual conflict between the regime and the Kurds,” she told Syria Direct.

“I can’t tell you where things are going, but I just hope that it isn’t more of a disaster than what we’re already experiencing.”