The Cable

Syria's War on Medicine

In late March, United Nations relief workers in Syria received a long-sought green light to deliver aid to tens of thousands of desperate residents of Douma, one of several villages outside Damascus that have been besieged by the government of Syrian strongman Bashar al-Assad for nearly two years, according to a pair of unpublished U.N. reports obtained by Foreign Policy.

By the end of the month, U.N. trucks had ferried food rations for 5,000 people into the town, along with sizeable quantities of nutritional supplements for local children and plastic sheeting for temporary housing for Syrians whose homes had been destroyed in the fighting.

But there was one item the U.N. was prohibited from bringing into the town: medical supplies. On March 29, Syria specifically blocked a U.N. truck carrying medicines and other medical supplies from entering Douma, according to an internal report by the U.N.'s Office for the Coordination Humanitarian Affairs, or OCHA, that was obtained by Foreign Policy.

Since the beginning of the Syrian conflict, the Syrian government has conducted a multi-pronged assault on the country's medical system, targeting doctors suspected of treating its opponents, bombing hospitals, clinics and blood banks in opposition areas, and denying deliveries of life-saving medical supplies to rebel-held areas. Syria's armed opposition has also targeted the country's medical workers and denied medicines to some communities considered loyal to the government, though on a much smaller scale.

In the coming weeks, the U.N. Security Council will begin deliberations on how to coax or compel Syria's combatants to meet their obligation to ensure that the sick and wounded have access to medicines and other relief goods.

But in a report distributed late Wednesday night to representatives of the 15-nation council, U.N. Secretary General Ban Ki-moon provided a decidedly downbeat assessment, noting that "none of the parties to the conflict have adhered to the demands" of the Security Council to ensure the free flow of relief supplies for many of the more than 9 million Syrians in need of assistance, particularly those trapped in hard to reach conflict zones.

"Thousands of people are not getting the medical care, including life saving medicines, that they need," Ban wrote in a 21-page report assessing the Syrian combatants' compliance with a February Security Council resolution demanding that they provide unfettered access to international relief workers or face unspecified consequences.

Ban noted that the parties have legal obligations under the Geneva Convention to ensure that the sick and wounded receive medical care. "Yet, medicines are routinely denied to those who need them, including tens of thousands of women, children, and elderly. The Security Council must take action to deal with these flagrant violations of the basic principles of humanitarian law."

Despite the tough words, the United States and other Western powers will have a tough time persuading Russia, which has served as the Syrian government's main defender on the council, to hold off from vetoing a potential resolution designed to formally sanction Assad for his refusal to allow the transit of medical supplies. Relations between Moscow and the West have plunged to their lowest point in decades because of Russia's recent annexation of Crimea, which triggered a set of punitive financial sanctions by the Obama administration and its European allies.

Syria has provided just enough cooperation with the international community -- granting limited access to relief workers, supporting polio eradication efforts, and destroying most of its chemical weapons -- to ease the political pressure at the U.N. to impose penalties on the government. But it continues to flagrantly violate its legal obligations under international humanitarian law in an effort to starve out pockets of potential support for Syrian insurgents, according to human rights advocates. A cornerstone of that strategy is a concerted government effort to limit the supply of medicines and other medical supplies in rebel-held areas of the country.

"Medical supplies that would have assisted 216,015 people in hard to reach and besieged areas were either removed from convoys, or the convoys were not allowed to proceed," Ban wrote in his report to the Security Council. "The inclusion of surgical supplies or any item that may be used for surgical interventions (including bandages, gloves, injectable medicines, antiseptics, anaesthetic medicines) continue to be restricted by the government for delivery into opposition held areas."

For instance, according to Ban's report, the Syrian government has continued to prohibit the delivery of medicines and construction materials designed to build temporary shelters for the 15,000 civilians that returned to their homes in the besieged town of Madamiyet Elsham following a cease-fire agreement.

The internal OCHA report obtained by FP said there had been "several recent instances of medical and surgical supplies being removed from cross-line shipments of humanitarian supplies by government officials."

"From 22 March to 10 April, the U.N. and SARC [The Syrian Arab Red Cross] conducted 4 cross-line inter-agency convoys all to areas under opposition control," the report said. "Two of these convoys had medical supplies removed or blocked from proceeding."

The Syrian government has insisted that it is doing all it can to ensure that food and medical supplies reach civilians in besieged areas. "The government of the Syrian Republic continues the facilitation of access to all areas, including those hard to reach such as the recent aid distribution in Douma, Aleppo, Idleb and Al Yarmouk Camp," according to a letter from the Syrian mission to the United Nations to the president of the Security Council, Joy Ogwu of Nigeria. "According to the new measures adopted by the Syrian government, the [World Food Program] was able to increase the number of recipients of food aid to 4.1 million people ... and UNHCR was able to increase the number of recipient[s] of the non-food assistance to more than 1.5 million people since the beginning of 2014."

Those numbers can be misleading: Foreign Policy, which first obtained those figures, revealed that the increase was largely due to civilians fleeing into government-controlled territory in search of food.

Syria has proposed a couple of changes designed, it says, to make it easier for aid to enter the country. One plan would involve Syrian officials in neighboring countries place seals on trucks delivering humanitarian relief into Syria. Government officials inside Syria would then be able to check whether anyone had tampered with the seals in an attempt to smuggle weapons onto the trucks. It also proposed a plan that would allow the U.N., along with the Syrian Arab Red Cross, to send surgical teams in mobile health clinics to besieged areas. The clinics, which would be administered by the Syrian government and the Syrian Red Cross, would be set up in the "no man's lands" between government- and opposition-held areas.

Widney Brown, the program director for Physicians for Human Rights, which has been tracking attacks on health workers, said the Syrian proposal was deeply alarming.

"If services are in effect provided by government-vetted doctors the question is: will they be impartial and provide medical assistance to, say, a wounded combatant who is a member of the opposition forces and not turn them over to the Syrian government?" she said.

Brown added that wounded or sick Syrians shouldn't "have to go to a government-run clinic to get treatment," especially since the Assad government has spent years deliberately targeting civilians.

Preventing medicines from being delivered to conflict zones has long been considered a violation of international humanitarian law. But both the government and some rebel factions in Syria's brutal civil war have tried to prevent medicines from reaching communities suspected of sympathizing with their enemies. Syrian doctors and nurses have paid a high price: Since the beginning of Syria's conflict, more than 68 public health workers have been killed and another 100 injured.

"The conflict has had a devastating impact on the Syrian health care system and infrastructure, severely undermining people's access to medical care and assistance," according to the OCHA report obtained by FP. "This has included the direct targeting of hospitals, medical personnel, and transports, denial of access to medical care, and ill treatment of the sick and the wounded.

The government fears that medical supplies -- particularly items like antibiotics and surgery equipment -- will be used to heal armed combatants, allowing them an opportunity to return to battle. Some of their opponents have come to feel the same way.

Insurgents have prevented food and medical supplies from reaching government forces and civilian residents in the pro-government towns of Nubul and Zahra in northern Aleppo, according to Ban's report. The U.N. secretary general noted that the Syrian government had given its approval in early April for relief convoys to travel to the areas, only to have rebel groups refuse to allow them through.

Widney Brown said that Assad's war on the country's medical system began gradually but evolved into a sustained and systematic campaign that has included detaining and torturing doctors and bombing clinics, blood banks, and pharmacies. "The government decided to treat doctors as if they were the enemy," she said.

Brown said the majority of those attacks were carried by the Assad government, but stressed that her group was "definitely seeing an increase in the number of attacks by the opposition."

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The Cable

Top European Mediator: Ukrainian Military Push Could Escalate Tensions

A Ukrainian military push into the country's restive east after the brutal murder of a local politician would complicate efforts to reduce tensions between Kiev and Moscow and prevent further violence in the country, the head of the international organization charged with helping resolve the crisis said in an interview.

Last week, major powers meeting in Geneva tasked the Organization for Security and Co-operation in Europe (OSCE) with helping end the violence in the country. The Geneva agreement did not specifically prohibit security operations by Ukraine, but it called on all sides to refrain from violence. Under the terms of the deal, the pro-Russian militants occupying government buildings throughout eastern Ukraine were supposed to leave the facilities under the watchful eye of the OSCE. The deal has in many ways fallen apart, with pro-Russian fighters solidifying their control over several cities and showing no signs of disarming or leaving the occupied buildings.

Lamberto Zannier, the secretary general of the OSCE, said a new Ukrainian effort to oust the militants had the potential to setback international efforts to reduce tensions. "The whole spirit of Geneva was promoting de-escalation," he told Foreign Policy. "It's certainly tough at this moment."

On Tuesday acting President Oleksandr Turchynov ordered his forces back to eastern Ukraine after the murder of local politician Vladimir Rybak, a member of the president's own Fatherland party. The move immediately raised fears of open conflict between Ukrainian security personnel and heavily-armed, well-entrenched, pro-Russian militiamen. That type of confrontation would be particularly dangerous because top Russian officials have openly threatened an armed intervention into eastern Ukraine to protect fellow Russian speakers there.

"Russia is increasingly called upon to save southeastern Ukraine from chaos," read a statement from the Russian Foreign Ministry on Monday.

Zannier acknowledged the risks of further escalation in the wake of Rybak's death. In a statement earlier Tuesday, Turchynov said his compatriot's corpse was found near the separatist-controlled city of Slaviansk. He said Rybak had been tortured to death and said "the terrorists who effectively took the whole Donetsk region hostage have now gone too far." The Ukrainian leader said he was ordering his security forces to resume operations in the east -- a situation that could pose problems for Zannier's organization. "This will require us to redouble our efforts ... and invite everyone to engage in a peaceful manner," Zannier said in an interview.

That might be easier said than done. In recent days, OSCE monitors have been blocked from entering various occupied buildings in the east, and stopped at checkpoints leading into separatist-controlled areas. That's obstructed monitors from fulfilling their primary task: overseeing the disarming of illegal groups and the evacuation of government facilities.

Currently, pro-Russians mobs continue to occupy buildings throughout eastern Ukraine, including at least nine towns. While Kiev is calling for the pro-Russian mobs to disarm and vacate the government buildings, separatists have called for more autonomy or in some cases independence from Ukraine. The job of the OSCE is to bring both sides closer together, but Zannier conceded that there's been little success on this front -- and said that the Russians have been less than helpful.

"I would welcome stronger messages from Russia inviting [separatists] to abandon buildings and engage in dialogue," he said. "On Russian television, we hear the same arguments" concerning the "illegality of the government in Kiev" and "extremist right-wing groups."

Russian officials say they agree that the pro-Russian separatists should disarm, but insist that right-wing nationalists in western Ukraine do so as well. While Zannier acknowledged that such nationalist groups exist, he downplayed their role in the conflict. "Everyone should disarm, but at this point, we see many more weapons in the hands of these pro-Russian radicals in eastern Ukraine ... than in the arms of right-wing extremists."

The growing tensions in Ukraine have brought the American-Russian relationship to its lowest point in decades and brought new prominence to the OSCE, whose roots date back to the cold war, where it provided a venue for dialogue between east and west. It became a permanent institution in 1994 with the goal of helping fledgling European democracies mature and develop. While Russia has been historically mistrustful of its aims, it did sign onto its conflict-resolution role in the current Ukrainian crisis. Still, hardened differences between east and west aren't Zannier's only problem. 

He says the OSCE needs more personnel and resources from OSCE member nations to properly do its job. "Ukraine is a large country and the area we have troubles in is pretty large," he said.

Zannier made the same plea at a special session of the OSCE's permanent council earlier on Tuesday. At present, he said the OSCE had 150 personnel on the ground, a figure he wanted to increase to at least 500. He said member nations support his requests in principle, but acquiring the resources has taken time.

A larger footprint in the country is critical to fulfilling the OSCE's monitoring role, he said, given its responsibility to provide credible information about events on the ground. "There is a propaganda war with different versions of the story," he said, referring to glut of conspiratorial claims by various actors in the conflict. "So having an international presence helps."


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