Conflict and health

The conflict has resulted in profound disruption in the relationship between citizens and state institutions. State institutions have withdrawn from and/or have been completely delegitimised in some territories, and there is a lack of confidence in their ability to govern in others.15 This has resulted in a vacuum that was filled with de facto powers in various parts of Syria, all pursuing legitimacy and autonomy, leading to de facto partitioning. Currently, about 13 million Syrians reside in 60% of Syrian territory governed by the Government of Syria (GoS); 2.6 million Syrians reside in northeastern Syria (approx. 30% of Syria) governed by the Autonomous Administration of North and East Syria (AANES); and 4 million Syrians reside in northwestern Syria (approximately 10% of Syria) under the control of various de facto powers.13

During the conflict, the health system was subject to destruction of infrastructure, attacks on and exodus of health workers, several outbreaks of communicable diseases, and a weaponisation of healthcare services mostly attributed to the GoS.16–18 In GoS areas, a shrinkage in the public health system occurred, with severe reductions in health services.19 In the Northwest, state institutions were replaced by humanitarian organisations.20 In the Northeast, the more ambiguous political status produced weak and redundant health systems.21 The politically driven curtail on humanitarian crossings to this region limited humanitarian access outside of the GoS mechanism. With minimal presence of GoS in the Northeast, health services were further reduced.21

Characterisation of health initiatives

A comprehensive account of all health initiatives over the past decade is beyond the scope of this paper. Nonetheless, general characterisations of these initiatives can be made. The majority of healthcare initiatives at this level addressed combat-related health needs, and sustained public health service given the collapse of the public health system.13 The restrictions of international humanitarian agency access to armed conflict areas, mostly imposed by GoS,22 resulted in a segmented regional scope of health initiatives. The extensive needs were material-intensive and infrastructure-intensive, requiring large amounts of funding from international agencies17 and engagement of various actors, often politically involved in the conflict.23 Implementing agencies were the Ministry of Health in GoS areas, a number of humanitarian, mostly diaspora-lead organisations in non-GoS areas, and self-proclaimed health authorities such as Idlib health directorate in the Northwest and AANES in the Northeast.20 24

Peacebuilding attributes of health initiatives

There is little evidence that these initiatives helped build dialogue and meaningful collaborations between states authorities and medical communities, health equity and citizen-state trust—the peacebuilding goals stipulated by WHO for health initiatives at this level. Rather, health initiatives at this level exhibited many conflict-prone components that are likely to have limited their peacebuilding capacity. Since most initiatives were in the context of active military combat, they were often subject to politicisation25 and weaponisation.18 Their large funding budgets and need for centralised logistics made them attractive for cooptation through taxation and diversion of aid funds, which were often funnelled in corruption channels or armament.12 26 27

Given that these initiatives were the main venue for healthcare provision, they were prone to competition for credit to establish and maintain legitimacy and loyalty among citizens. This led to concerns about inequal distribution to harness loyalty, which further deepened citizen-state mistrust.28 This was clear in dealing with COVID-19; while the GoS was in charge of the vaccination and testing for the Syrian Arab Republic, it had limited operational capacity in the Northeast and none in the Northwest. This shortcoming—due to lack of capacity or intent—led to the GoS’s failure in capitalising on an opportunity to rebuild citizen-state trust.29

Conflict and health

Intraterritorial conflicts between various state and non-state armed factions have been a key characteristic of the conflict. While more consolidation took place in GoS territories, during the war various interterritorial division existed with besieged areas such as Eastern Ghouta had major health crises.30 Residues of the armed conflict in Dara’a, Southern Syria resulted in renewed conflict between various armed factions31 and also with neighbouring armed factions in Swaida.32 These dynamics were magnified in the more anarchic Northwest where there is no central authority. Various armed groups competed over legitimacy and governing powers.20 Less profound conflict exists in the Northeast, where Kurdish-lead AANES exerts authority over a large part of the Northeast.

The power struggle at this level has manifested in deeper healthcare sector fragmentation with armed de facto powers each creating their own health ‘system’, competing over funding, and fighting to gain legitimacy. This has yielded uncoordinated healthcare structures that are redundant, underfunded, underequipped and undergoverned.20

Characterisation of health initiatives

Health initiatives at this level share many attributes with those at the citizen-state level. This is especially evident in the Northwest, where many competing armed groups exist and belligerents see health as a weapon of war.20 Health facilities were often the first to be targeted in order to demoralise fighters and communities. The recent dwindling armed conflict allowed for more non-combat health services, especially in the context of the COVID-19 pandemic. There was also still heavy emphasis on material intensive care such as building intensive care units, providing ventilators and specialised care.33 The geographical scope of these initiatives remained very territorial, following de facto powers domains and donors mandates.20 Internationally funded diaspora organisations with perceived political stigma were the main implementers. Across the different factions, healthcare is perceived to be a venue for establishing and sustaining legitimacy and relevance.

Peacebuilding attributes of health initiatives

Health initiatives at this level also fell short of achieving meaningful crossline collaborations to address shared health concerns,3 demonstrating a high-burden of conflict-prone characteristics. During the peak of the armed conflict, crossline transport and exchange deals (coauthor ZA was actively involved in those) achieved minimal peacebuilding outcomes, given that they were occasional, largely transactional and based on narrow interest calculations with no intention to build trust. Also, such deals often required financial incentives to belligerent parties, becoming a venue for taxation and diversion of aid funds into the armed conflict as a USAID probe investigation revealed.12 26 27 Such outcomes are similar to those observed in other humanitarian initiatives between armed factions.4

Serious attempts were made by political actors, such as the Syrian Opposition Coalition with the support of international donors, to integrate the various components of health systems in the Northwest,20 and now between the Northwest and Northeast,34 without success. Healthcare was viewed as a tool to gain legitimacy among group subordinates, delegitimise rivals, and to pressure opponents. Hence, there was no incentive for de facto powers to engage in cross-authority work. This is evidenced with health interventions related to the COVID-19 response also failing to induce meaningful collaborations at this level.20

Conflict and health

The political struggle in Syria contributed to the disintegration of Syrian society along a myriad of schisms.11 15 Unlike the combat-based interbelligerent conflict between armed factions, the intercommunity conflict represents widespread disruptions of relations between communities at large, risking long-term social institutionalisation of the conflict.

Notwithstanding relatively limited research at this level and acknowledging the local heterogeneity of conflict experiences of individuals and communities across Syria, there is substantive documentation of the overall patterns of social degradation in the country.15 While occurring in the context of the main political conflict, intercommunity conflicts reflect different motives. The immense conflict-related psychosocial trauma, the dire needs and the limited resources experienced by most Syrians, increased intercommunity and intracommunity security competitions along various socioeconomic schisms.

One example of a tangent, but profound intercommunity and intracommunity schism is that between ISIS-connected tribes/families and neighbouring communities of ISIS victims,35 36 which occurred mostly along prior intertribal or agrarian-pastoral conflicts.37 Many other conflicts were aggravated along sectarian,38 ethnic39 and tribal schisms40 with increasing insecurities bringing about ever-narrowing definitions and narratives of ‘us vs them’.41 For example, the intercommunity conflict in Southern Syria between Swaida and Dara’a residents with tit-for-tat kidnapping and severing of traditional socioeconomic relations between neighbouring towns, despite a limited and remote history of direct conflict.42

The impact of socioeconomic collapse on public health services is just as destructive as the armed conflict itself.43 Health services are now even more clustered in urban centres with further privatisation of profitable health sectors, accentuating health inequalities that predate the war.44 45 Social disintegration disrupted traditional community patterns of day-to-day healthcare. Many rural and tribal communities’ lost connections with their traditional healthcare provider, now across-the-line. The shortage of community healthcare workers due to attacks on healthcare workers46 is further exacerbated by the exodus of physicians following the recent economic collapse.

Characterisation of health initiatives

Given their scale, and the lack of a comprehensive scholarly work, knowledge of community-based health initiatives is limited to those linked with research projects, mostly addressing Syrian refugees,47–50 in addition to fieldwork experience. These health initiatives vary from fundraisers seeking to address health needs among the needy, to community-based healthcare programmes48 49 51 and community volunteer campaigns facing health crisis such as COVID-19.50 52

These initiatives mainly address basic health needs for individuals in need or for communities facing shared threats such as COVID-19. The geographical scope is mostly restricted to local communities. They rely heavily on local and diaspora charitable donations and fundraisers. They are often implemented by local civic society organisation and volunteer medical community members, with credit often attributed to community members.

For example, COVID-19 elicited a collaborative community response in the Northwest where prior political attempts had failed: a number of technical health entities used limited resources, open-source services and volunteer campaigns that included locals and diaspora members to combat COVID-19.50 A very similar community response was observed in Swaida in Southern Syria with a community campaign ‘lets pass together’ spontaneously mobilising volunteer health professionals to perform home visits and donations to combat COVID-19.52 One of the authors (MA) was involved in iniatives in Swaida, while another (ZA) was involved in initiatives in the Northwest and GoS areas, where physicians involved in crossline educational sessions included fellow physicians and community leaders.

Peacebuilding attributes of health initiatives

Unlike upstream levels, community health initiatives demonstrate trends to advance towards peacebuilding by engaging community members in collaborative efforts to overcome the physical and mental health scars of war and address shared threats.3 Despite COVID-19 increasing health insecurity and inequalities as well as sharpening intercommunity and intracommunity competition over oxygen supplies and hospital beds,53 it also induced a collaborative response via community initiatives to face the pandemic.50 52 The favourable peacebuilding outcomes at this level are in line with the findings of one of the most prominent peace and health initiatives with horizontal interventions targeting community conflict in Bosnia and Herzegovina.54

The COVID-19 response across the three levels of power structure provides a good opportunity to contrast elements of health initiatives at these levels and identity their conflict-prone and propeace attributes. At state citizen level, the COVID-19 response focused on securing capital-intensive, material-dependent health needs such as PCR testing, vaccination, isolation units and intensive care units.29 These operations were implemented by state institutions and de facto authorities with inefficient execution and ongoing concerns of corruption and diversion of funds. At the community level, in contrast, there have been organic pro-peace trends which have been driven by scarcity and a common threat. Initiatives largely relied on volunteers and were more labour-intensive, unleashing potent psychosocial healthcare forces of empathy, solidarity and trust. Credit was shared among various stakeholders, including local and national authorities.52 These attributes made such initiatives propeace and minimised their predisposition to cooptation.

Conflict levels and areas of intervention

Based on this analysis, the intracommunity and intercommunity levels of the conflict are likely the most amenable to peacebuilding initiatives. Areas with low conflict legacy, low political tension and spontaneous collaborative tendencies serve as optimal starting points. Accordingly, the Governate of Swaida in Southern Syria was identified as an appropriate candidate to implement a peace-through-health initiative.42 In 2020, COVID-19 health insecurities escalated existing intracommunity conflicts in Swaida with competition over oxygen supplies and hospital beds.

Health needs targeted

The labor-dependent component of a spontaneous community campaign, ‘Let’s Pass Together’52 (ie, home nursing visits) was the main health service provided in this pilot. To avoid entangling with existing community competition over oxygen supplies, the programme limited its role to providing communication infrastructure to rotate existing oxygen tanks and securing competitive pricing for oxygen refilling for programme participants.

Organisational model, funding, geographical scope and implementers

A diaspora-based, grassroots NGO working on humanitarian-development-peace nexus projects in Syria provided organisational and operational support, medical mentoring and grassroots funding. Given its distance from local struggles and its ability to secure funding, the diaspora NGO was able to subtly navigate local politics and help design the local organisational structure. Logistics were coordinated by a technical team from different local organisations. Operations covered most of Swaida with a ‘franchise-like’ model of centralised procedures and decentralised implementation. Healthcare workers signed up in the volunteer campaigns, and were compensated for home visits. Volunteer Syrian American physicians provided teleconsultation for local staff.

Navigating conflicts: power mapping, stakeholder and incentive structure analysis

Swaida Health Directorate (SHD), the Syrian Arab Red Crescent (SARC), prominent figures of the local medical community, medical staff, humanitarian NGOs and local leadership in control of oxygen supplies and vendors were all engaged. Based on some statements of local medical community at the beginning of the campaign, initially, the effort was perceived to undermine the authority of the SHD, which was struggling against a raging pandemic with limited resources. This led to them raising regulatory limitations of the campaign and its staff. There was also competition between prominent community medical figures and NGO over claiming credit for the campaign.

To overcome these power dynamics, the programme assigned organisational leadership to technical leaders from different organisations rather than prominent community figures. This minimised competition over credit. Clan leaders with oxygen supplies were incentivised to share their data by securing competitive oxygen refill pricing for participants, and providing free nursing services for their members. The programme identified incentives to promote collaboration with SHD and SARC, which included acknowledging SHD’s efforts in combating COVID-19 and improving the morale of their struggling health workers. As such, the campaign was framed as a collaboration between the community and the SDH to offload the burden placed on local hospitals to home services. In addition, financial gifts were provided directly to SDH staff and SDH was publicly credited for securing these bonuses. While no financial incentive was provided to any official, the arrangement proved successful in securing a constructive collaboration through the campaign.

Pilot project peacebuilding outcomes

The intracommunity peacebuilding outcomes for the pilot project are in line with the WHO goals for Health and Peace.3 Diaspora and local technocrats worked together. More than 90 nursing teams of nurses were recruited, trained and deployed across the governorate with a focus on underserved areas using SDH medical points. Coordination with the SARC was secured to use their hot line and dispatch service, which was imperative and useful. Volunteer nurses were equipped with medical supplies, personal protection equipment and were compensated for their home visits from diaspora and local donations. The local team was able to tally oxygen tanks in the community across the governorate—information that was previously not shared due to competition. Per programme reports, more than 2000 patient homes visits were delivered, hospital admissions were reduced, and 110 nurses were employed over a period of 6 months.

Using the infrastructure that this COVID-19 campaign created, the programme is currently being expanded towards intracommunity peacebuilding, targeting other acute medical conditions with a focus on intercommunity interfaces in rural areas at the frontiers of conflict lines in Southern Syria with Dara’a to the West and Bedouian communities to the East. Similar programmes are being planned in areas with similar conflict legacies and power structures such as East Homs and AlHasaka in northeastern Syria. Such projects can be adapted as a part of a multipronged programme actualising the humanitarian-development-peace nexus to promote progressive collaboration at the intercommunity level and beyond across Syria.