Hypocritic Oath

How WHO and other international agencies aid Assad’s war against Syria’s civilians.

Eastern Ghouta, a lush, semiagricultural region just 10 miles northeast of Syria’s capital, was once the breadbasket of Damascus. Known for its liberal-minded residents, religious and ethnic diversity, democratically inclined politicians, and independently wealthy entrepreneurs, it has long been loathed by Syrian leader Bashar al-Assad and his regime. In August 2013, Eastern Ghouta was the target of the Syrian government’s sarin gas attack, which killed 1,466 people in a single night, mostly women and children.

In the immediate aftermath of the sarin massacre, facing the credible threat of international force, the Assad regime ratified the Chemical Weapons Convention and agreed to hand over its stockpile to Russia. For a few weeks, the airstrikes ceased. Then, in October, the Syrian military began its siege of Eastern Ghouta in earnest.

Siege has been a central part of Assad’s response to the popular uprising, evident since the first siege of the city of Daraa in March 2011. By the fall of 2016, Assad’s forces were besieging more than 1.2 million civilians — in large urban areas such as eastern Aleppo, small civilian towns such as Darayya, and Palestinian refugee camps such as Yarmouk. Other armed groups have also besieged civilians — the Islamic State besieged 80,000 people in Deir Ezzor, and Sunni opposition forces besieged 20,000 Shiite civilians near Idlib — but the numbers have not been nearly as high. The number of civilians besieged by the Syrian government today is approximately 700,000. More than half — 390,000 of them — are in Eastern Ghouta.

Sieges of combatants to induce their surrender are considered lawful warfare. But the Assad regime employs siege aimed at civilians in opposition-held areas as a form of collective punishment and control. That is a war crime. International humanitarian law requires free movement of civilians and humanitarian access to them — both of which have been routinely denied by Assad’s forces. The Syrian regime’s strategy targets civilians not only where they are commingled with combatants but also in purely civilian towns. The suffering caused by siege is slow and almost invisible.

Responsibility for this grim state of affairs lies mainly with the Syrian authorities, but U.N. humanitarian agencies, faced with the unenviable task of negotiating with a regime that has no qualms about killing civilians, have often played along. The posture adopted by senior U.N. staff assumes that whatever good they may be doing justifies the cover they provide for the sieges and other attacks.

The reality suggests otherwise. Darayya, an impoverished Sunni town a few miles south of Damascus, was besieged beginning in November 2012. The Syrian regime justified the siege by depicting the town as a military base so no humanitarian or medical aid was permitted to reach it. When U.N. officials finally visited in May 2016, they were shocked to find it was a community of some 8,300 women, children, and elderly civilians.

In another instance, in 2015 the U.N. Office for the Coordination of Humanitarian Affairs (OCHA) entered into an agreement with the Syrian government. On paper, the agreement provided a mechanism to evacuate sick patients from four towns: Zabadani and Madaya, besieged by pro-government forces, and Foua and Kefraya, besieged by armed opposition groups. In practice, it meant that people in areas besieged by the regime died. Regardless of whether the critically ill patient in Madaya was a schoolchild with meningitis, a mother with a complicated pregnancy, or a grandmother with breast cancer, evacuation had to wait until someone became ill enough to need evacuation from the opposition-besieged areas, even though those towns had the advantage of receiving government-organized airdrops of food, fuel, and medicine and did not face ongoing airstrikes by pro-regime forces. These rules applied even to 5-year-old kids suffering landmine injuries — very few of whom survived the wait.

In the same year, at the insistence of the Syrian government, OCHA removed every reference to “siege” or “besieged” from its 2016 Humanitarian Response Plan — a tacit recognition by the Assad authorities that their use of siege constitutes a war crime and a disturbing willingness on the part of OCHA to cover up that conduct.

Syria Civil Defence volunteers and rescuers remove a baby from a destroyed building in Aleppo on April 28, 2016. (Ameer al-Halabi/AFP/Getty Images)

Even though less than 5 percent of Eastern Ghouta’s population can be considered combatants, the Syrian government withholds permission for surgical supplies in convoys on the specious grounds that patients with war injuries must be terrorists. Yet the daily airstrikes by the Syrian and Russian governments targeting homes, schools, markets, mosques, ambulances, and hospitals mean that almost all patients suffering explosive injuries and limb amputations are civilians. Women and children are the most vulnerable, both to attacks and to the exclusion of surgical items, which includes prohibition of blood donations and blood transfusion equipment and intravenous fluids, which are essential for cesarean sections and the resuscitation of children.

Since 2013, WHO has spent millions of dollars on behalf of the Syrian Ministry of Defense to buy blood bags, transfusion equipment, cross-matching and screening kits for blood-borne diseases such as hepatitis B, hepatitis C, and HIV. WHO continues to subsidize the ministry even though none of those medical supplies are permitted to reach Ghouta. Meanwhile, the bombs dropped on Ghouta cause bloodshed that exposes medical personnel and patients to hepatitis B and C, HIV, and other blood-borne diseases. In a particularly sinister move, the Assad regime consistently removes all screening kits and hepatitis B vaccines from convoys going to areas besieged by its forces.

“Deletion” is code for the Assad authorities’ banning of surgical supplies and essential medicines from besieged areas. This policy is implemented first by the Ministry of Foreign Affairs; then by the Ministry of Health, which has an entire department, the Department of Preparedness, dedicated to “deletions”; and finally by the Syrian security forces that control U.N. and Red Cross warehouses.

When the Foreign Ministry approves a convoy, the Health Ministry cuts the list of hundreds of medicines considered essential in government territory down to a few dozen. Sterilization equipment is withheld, forcing surgeons to reuse surgical items without sterilization between operations. Intravenous antibiotics, anti-tuberculosis drugs, dialysis sets, polio and measles vaccines, iron and folic acid for expectant mothers, and formula and multivitamins for infants are either denied or supplied in pitiful amounts. Not even paper for the few electrocardiogram machines is permitted. In a cruel irony, WHO and UNICEF provide abundant supplies of lice shampoo and scabies lotion, which are permitted in unlimited quantities by Syrian authorities, even though they are not needed by civilians desperate for insulin and dialysis.

Even once this process of deletions is completed, pro-regime forces at checkpoints may remove items, such as dialysis equipment, or contaminate them, such as by mixing rice with bird feces or glass. One official, Dr. Al-Hajjaj al-Sharaa, the director of the Department of Preparedness, also heads the Al-Sham Foundation, an Assad-approved nongovernmental organization and a major implementing partner for WHO and UNICEF. He is conveniently positioned to redistribute deleted items for his own political and financial gain. Another of WHO’s implementing partners, Al-Bustan Foundation, is owned by Rami Makhluf, Assad’s cousin and a well-known war criminal. Al-Bustan was placed on the U.S. Treasury Department’s sanctions list in May 2017 for its connections to Makhluf.

A member of the Syria Civil Defence carries an injured child following airstrikes on the outskirts of Damascus on Feb. 7. (Hamza al-Ajweh/AFP/Getty Images)

After the first miserable winter of 2013-2014, when the infant mortality rate skyrocketed to an estimated 300 per thousand live births, compared with 18 down the road in Damascus, the siege forced the construction of several secret tunnels connecting Eastern Ghouta to the Damascus suburbs of Barzeh and Qaboun, then under the control of opposition forces. The tunnels permitted not just food and commerce but also limited quantities of medical and surgical supplies, fuel for hospital generators and ambulances, and the sending of biopsies from cancer patients for diagnosis by cooperative labs in Damascus.

For two and a half years, these tunnels were Eastern Ghouta’s lifelines, providing thousands of patients with life-saving treatment and safe passage for tens of thousands more civilians who wished to leave the region. Then, after eastern Aleppo fell in December 2016, the Assad regime’s attempts to find the tunnels accelerated. By the end of February 2017, the warehouse hiding the exit point of the main tunnel fell under the control of the Syrian army, rendering it unusable. By mid-May, all four tunnels were breached, triggering self-destruct mechanisms to avoid giving the Syrian army direct lines into Eastern Ghouta.

Each month since then, doctors in Eastern Ghouta have sent a detailed list of urgent medical and surgical supplies and essential medicines such as insulin to the Health Cluster in Damascus, a group organized by OCHA and led by WHO. They also repeatedly request critical medicines such as prednisolone and methotrexate. Yet few convoys are allowed, and the contents of approved convoys fall far short of the basic clinical needs of the most vulnerable patients — women and children.

In what amounts to a whitewashing of the siege, U.N. reports on the convoys describe only the weight of items delivered and those deleted, as if a half a ton of lice shampoo is the medical equivalent of a 500-kilogram oxygen generator or a 50-kilogram wheelchair is worth more than 50 milliliters of adrenaline — enough to restart dozens of hearts.

The deprivation in Eastern Ghouta is all the more alarming because it is occurring down the road from specialized labs and pharmacies in Damascus and the U.N.’s vast humanitarian apparatus in the city, which includes World Food Program and UNICEF warehouses stocked with food and nutritional supplies, WHO’s piles of essential medicines and equipment, and hundreds of U.N. and other international aid workers. Douma, Eastern Ghouta’s largest city, is less than 10 miles from WHO’s office in Damascus and the luxurious Four Seasons Hotel frequented by U.N. agencies. During an earlier siege, while WHO officials ordered French pastries and chocolate chip cookies for their Health Cluster meetings at the Four Seasons, kids were eating grass and drinking from puddles in Darayya.

On Oct. 26, 2017, 430 critically ill patients needed evacuation from Eastern Ghouta. A high-level teleconference led by OCHA yielded an agreement to evacuate 29 patients within 48 hours to Damascus. It took an entire night of painful deliberations for Eastern Ghouta’s doctors to decide which 29 would benefit most from evacuation. On Oct. 27, this list was sent to OCHA, copying WHO and UNICEF. Nothing happened. Over the next two months, 18 of the 29 patients died.

In despair, the doctors wrote a highly unusual letter to the WHO’s director-general, Tedros Adhanom Ghebreyesus, asking WHO for criteria to help less academically qualified doctors decide who should live and who should die. A copy of the letter was sent to U.N. Secretary-General António Guterres. Tedros never responded. Nor did Guterres.

However, within days, both Staffan de Mistura, the U.N. special envoy for Syria, and Jan Egeland, his humanitarian advisor, made strong statements, and the Syrian government finally approved the evacuation of 29 patients. The doctors compiled a new list, replacing the dead, as well as those who wouldn’t risk transfer to government territory for fear of arrest. Even then, when evacuation finally took place on Dec. 26, the government allowed it not as a humanitarian matter but only as an exchange for 29 captured combatants detained by a militia in Eastern Ghouta — in essence, using critically ill civilian patients as pawns in its military plans.

To put this in historical perspective, during the siege of Leningrad in World War II, 1.3 million civilians were allowed to leave unharmed. During the 1992-1996 siege of Sarajevo, hundreds of patients were medically evacuated safely.

In an Al Jazeera interview on Jan. 8, WHO’s Syria director, Elizabeth Hoff, defended this state of affairs, saying, “As far as WHO is concerned, we have done everything in our power to try to assist with the medical evacuation.” What she didn’t address is why WHO keeps asking for hundreds of millions of dollars for medical supplies that demonstrably do not go to those who need it most in Eastern Ghouta and instead benefit NGOs run by Assad’s family and friends. By continuing to subsidize the Syrian military as it targets civilians and imposes deadly sieges, WHO is relieving the regime of the burden to purchase these items itself. The effect is to give the government more funds to purchase the bombs used to target hospitals and other civilian institutions.

A similar subsidy comes from U.N. operations in Damascus. At Syria’s insistence, the U.N. distributes the bulk of its billions of dollars of aid through Damascus. There is no evidence that these funds are distributed to those in greatest need.

The U.N. justifies this state of affairs on something akin to a trickle-down theory — that some people will eventually get something. But that claim ignores the role of this aid in enabling the Syrian government to continue to pursue its war crimes. Meanwhile, the people in greatest need — who should be WHO’s priority — continue to be killed in airstrikes or are left to die due to the deliberate denial of food and medical aid that WHO is enabling.

Four and a half years into the Assad regime’s siege warfare, U.N. agencies have failed to address the fundamental question of whether, by subsidizing these atrocities, their operations in Damascus are doing more harm than good.

Correction, Sept. 19, 2018: Al-Bustan Foundation was placed the U.S. Treasury Department’s sanctions list in May 2017. A previous version of this article mistakenly said Rami Makhluf, who was sanctioned years earlier, was placed on the list then.

Annie Sparrow is a medical doctor and assistant professor at the Arnhold Global Health Institute at the Icahn School of ­Medicine at Mount Sinai Hospital in New York. (@annie_sparrow)