• OMSG Editor

The Grassroots Organisation Directing Health Efforts in Rebel-Held Syria

Sarah Yazji, St Catherine's College

In Syria, healthcare is under fire.

The ruling Assad regime weaponised access to medical services when anti-government protestors marched across the country in 2011. Secret police and shabiha, or state-sponsored ex-prisoners, terrorised ambulance workers, nurses, and doctors who treated injured demonstrators. In 2012, the government enacted an ‘anti-terrorism’ law forbidding medical aid to anyone sympathetic to the revolution. Targeted airstrikes decimated ambulances and medical buildings. The government kidnapped, tortured, and killed over 900 medical workers who chose to remain in Syria and deliver care1. In this tragic setting, grassroots medical efforts outside the eyes of the regime emerged. In Syria’s northern Idlib governorate, the Idlib Health Directorate was formed.

Creating a medical institution to serve the Syrian people

In March 2020, when Oxford Medical School suspended clinical placements and the UK instated a nationwide lockdown, I came across a video titled ‘Recommendations of Dr. Munzer Khalil, Director of Idlib Health, Regarding Corona Prevention’2. In this nine minute segment in Arabic, Dr. Khalil addresses the people of Idlib, Syria. He reports there are no confirmed Covid-19 cases in Idlib, but warns that either it is already spreading or will enter the population soon. Dr. Khalil speaks plainly and practically. Leave your homes only when absolutely necessary. Avoid visiting elderly relatives. He demonstrates the right way to wash your hands, to cover a cough, and ends with: ‘I pray for everyone’s safety. Peace be upon you all.’

Dr. Khalil heads the IHD and has done so since its inception seven years ago. At 38 years old, an orthopaedic surgeon by training with a background in hospital management, he is intimately involved in the response to the pandemic in liberated Syria. No legitimate government serves the 4.2 million people residing in this opposition-held region extending across Idlib governorate to parts of Aleppo3. In response to a decimated healthcare infrastructure, five doctors formed the IHD in 2013. Seven years later, their brain child serves as the technical health authority in Idlib and represents over 200 medical facilities with 141 employees.

The Directorate’s objective is clear: it not only works to fill the gaps left by a ruined infrastructure, but also seeks to provide for the Syrian people an alternative to former government institutions. Representation, fair elections, and ‘good governance’4 form the backbone of this grassroots body in order to gain legitimacy and trust from the people it serves5. The IHD represents every hospital and primary health centre in Idlib governorate. In Dr. Khalil’s words, the IHD biennial board elections are ‘the largest democratic election process in opposition institutions.’

Expanding beyond conflict medicine

In 2012, Dr. Khalil and others noticed a drop in routine immunisations in northern Syria. This was yet another regime tactic for depriving a disloyal mass. ‘Vaccines were used as a form of collective punishment for the region,’ Dr. Khalil explained. He contacted the office in charge of vaccinations in the Syrian government at the time, insisting children’s vaccinations should be separated from the conflict. While the office was sympathetic, nothing changed. In October 2013, 15 years after the last reported case in Syria, polio reemerged in the country’s northeast.

The polio outbreak expanded the IHD’s focus from conflict medicine to supporting all health services in place of dysfunctional government facilities. With only 6 staff members at that time, the IHD mobilized 3,000 volunteers in a successful polio vaccination campaign supported by international NGOs, UN agencies, and the WHO6.

Now the IHD covers all aspects of medical care in Idlib, from primary health and pharmaceuticals to tertiary care and forensic medicine. Operating in a region with no legitimate governing body, the IHD’s administrative branch ensures technical aspects of health delivery are met. This includes medical buildings and equipment, human resources, quality control, and legal affairs.

Under fire from Covid-19

Idlib witnessed a devastating winter leading up to the pandemic. In December 2019 the Assad regime and Russia launched a relentless military offensive on the civilian population. In the space of a few months 1.2 million civilians, a number eight times the population of Oxford, fled to the Turkey-Syria border. Camps swelled to over 400% capacity. Impoverished and traumatised families sheltered in abandoned structures. Idlib lost over 70 medical facilities to airstrikes. In March 2020 not a single ventilator of the 30 left in the region was available for Covid-19 patients7.

The IHD focused on delaying the arrival of the virus until the medical sector was ready to receive patients. The Directorate partnered with the Syrian Civil Defense and attracted 8,000 civilian volunteers for community awareness and public health campaigns8. The IHD worked closely with medical aid organisations on the ground as part of a WHO-led Covid-19 task force. One leading organisation founded by expatriate Syrian doctors across Europe and North America, UOSSM, delivered training to local healthcare workers receiving Covid-19 patients and established community isolation centres9. The task force assigned seven hospitals and 31 community centres to the Covid-19 response, implemented a community referral system, and prepared the only laboratory in northwest Syria for viral testing10.

The IHD collaborated with researchers abroad to ensure best practice. It most recently partnered with a researcher from the University of Oxford to develop predictive models for various community-level interventions.

The North Syria Covid-19 response is not without its challenges. Dr. Khalil pointed to the fact that their work hinges on donations from international supporters. Personal protective equipment for healthcare workers are scarce due to regional shortages. Social distancing, proper hand washing, and stay-at-home measures are luxuries when shelters are overflowing, clean water is scarce, and families depend on daily work to feed themselves. Face masks, the most feasible preventative measure in this setting, have not been secured for the general population. Oxygen supplies are alarmingly inadequate when an estimated 20% of infected patients require oxygen support11.

Moreover, the geopolitical situation continues to deprive Syria’s people of medical care. The Syrian government denies high numbers of Covid-19 cases in the country despite limited testing and Syrian doctors warning otherwise12. In July 2020, despite an ongoing pandemic, the UN Security Council failed to secure cross-border aid from Turkey and Iraq. The crossings are a lifeline for millions in the north of Syria who rely on them for food, medicine, and basic needs. Of the four original major crossings, the UN only approved the continued use of one13.

And most tragically, the indiscriminate bombing of civilian homes has not stopped. Syrians in Idlib are not just threatened with death from a fatal virus, but more imminently from the ongoing air campaign in the region’s south14.

Building a Syria for all

For Syrians, the IHD is an ongoing success story. It continues to battle odds in a perilous setting. Dr. Khalil believes it demonstrates what a state institution should do: represent the people it serves and respect their dignity and rights. He hopes the IHD model will ‘incite the rest of society to establish other alternative institutions, such as the directorates of education and agriculture.’ This past September 2020, the IHD held its third general conference with 140 medical facilities represented. A new board was elected.

Dr. Khalil did not run for his board position this fall. He stepped down from his work of seven years to pursue a Master’s Degree in Health, Policy, Planning, and Financing in a course developed between the London School of Hygiene and Tropical Medicine (LSHTM) and London School of Economics (LSE). During the writing of this piece, Dr. Khalil moved to London with his wife and two young daughters. His hope is to return to his homeland one day soon equipped with the knowledge and training to help rebuild Syria’s healthcare system.

Dr. Khalil was a demonstrator in the earliest anti-government protests before taking on the duties of coordinating and delivering medical care to his people. Reflecting on his experiences, he could not help but emphasize the innumerable others who served the health needs of Syria’s people. He named close friends and colleagues who were martyred in their shared pursuit. For him, the directorate will remain a success story so long as it remains ‘the property of the society it serves.’

Quotations from Dr. Khalil were taken from personal interviews conducted with him for this piece and reproduced with his permission.

Edition: 69 (2020-2021)

Correspondence to: editors@omsg-online.com


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