How a UN health agency became an

apologist for Assad atrocities

By remaining silent over the systematic destruction of Syria's

healthcare by the government and its allies, WHO is complicit in
war crimes Annie Sparrow claims

Monday 16 January 2017

For years now, the World Health Organisation (WHO) has been
fiddling while Syria burns, bleeds and starves. Despite WHO Syria
having spent hundreds of millions of dollars since the conflict
began in March 2011, public health in Syria has gone from
troubling in 2011 to catastrophic now.

To put this in perspective, while life expectancy for someone born

in the United States has risen half a year from 78.7 years in 2010
to 79.3 years in 2015, over the same time period in Syria, it has
plummeted more than 15 years from 70.8 years in 2010 to 55.4
years in 2015.
This new and devastating figure is comparable with South Sudan
(57.3) and considerably lower than Afghanistan (60.5), Rwanda
(66.1), and Iraq (68.9) while disturbingly, the global average life
expectancy for babies born in 2015 is 71.4 years, baby boys in
Syria can expect to live just 48 years, baby girls, 65 years.

Even Haitian babies can expect to live an average of 63.5 years,

despite two centuries of political turmoil and the worst rates of
infectious diseases such as HIV and cholera in the Western
hemisphere.

The reason for Syrias plummeting public health can be illustrated

by the final, devastating fall of eastern Aleppo.
Systematic bombing
Like the residents of Mouadamiya, Homs and Darayya before
them, the last quarter million civilians of eastern Aleppo and
10,000 members of militia succumbed after months of siege on
top of years of systematic targeting of civilian homes, hospitals,
schools and shops using missiles, barrel bombs, chemical attacks,
bunker busters, incendiary weapons and cluster munitions.
The main attackers have been the Syrian government of Bashar
al-Assad and its principle allies, Russia mainly from the air, with
support on the ground from Iran and Hezbollah.
Tens of thousands of civilians were evacuated from eastern
Aleppo to the western Aleppo countryside and Idlib governorate,
both still controlled by opposition groups such as Ahrar al-Sham
(the major rebel force) and Jabhat al-Nusra (the al-Qaeda affiliate
until it recently rebranded itself, claiming it had parted ways with
the group).
Such dislocation only exacerbates the health crisis faced by
roughly 2.5 million civilians in Idlib those displaced and their
host communities and the half-million plus in oppositioncontrolled parts of western Aleppo. And thats not even counting
the additional four million civilians living in other opposition-held
areas, more than one million of which live in areas still besieged

by the government.

Syrian civilians arrive at a checkpoint, manned by progovernment forces, after leaving Aleppo's eastern
neighbourhoods on 10 December 2016 (AFP)
That increases the need for WHO Syrias assistance, which should
be delivered according to need, the principle of impartiality, one
of WHOs founding ethical principles.
Yet WHO Syria has been anything but an impartial agency serving
the needy. As can be seen by a speech made by Elizabeth
Hoff, WHOs representative to Syria, to the UN Security Council
(UNSC) on 19 November 2016, WHO has prioritised warm
relations with the Syrian government over meeting the most
acute needs of the Syrian people.
READ: WHO's response to Dr Annie Sparrow's piece on its work in
Syria
Reflecting this misprioritisation, Hoffs presentation was rife with
inaccuracies, scanty on facts, and deeply skewed to favour the
Syrian regime. This bias can be illustrated by three particularly
disturbing parts of her presentation.

Misrepresentation of infectious diseases

First with respect to infectious diseases - a matter of global
concern because germs do not respect borders - Hoff spun the
Syrian governments efforts positively while concocting a central
life-saving role for her WHO office. She claimed that before the
conflict, national vaccination coverage rates were 95 percent
but now, almost six years later vaccination coverage rates
have dropped by half.
Hoffs endorsement of the governments inflated vaccination
claims help cover up its politicisation of this fundamental form of
health care
She also testified to the Security Council that polio, a lifethreatening childhood illness that re-emerged in Syria in 2013
after being eliminated in 1995, was re-eradicated thanks to
concerted efforts by WHO and UNICEF.
In fact, although the Syrian government insist that the national
polio vaccination coverage rate for 2009 and 2010 was 99
percent, WHO and UNICEF estimate that it was only 83 percent
and even this figure was accorded their lowest grade of
confidence due to the lack of supporting data. These estimates
and the contrasting official figures, are cited in WHO and
UNICEFs 2013 Global Polio Eradication Initiative Strategic Plan for
Polio Elimination in the Middle East.

Hoff briefs the UN Security Council in November 2016 (AFP)

Indeed, one reason behind the 2011 uprising in Syria was the
years of the Assad regime withholding standard vaccinations of
children which protect them from diseases such as polio,
pertussis and measles in areas considered politically
unsympathetic, such as the provinces of Idlib, western Aleppo,
and Deir Ezzor, while pro-regime areas such as Damascus and
Tartous received full coverage. The Syrian government insists
measles coverage was 99 percent in 2010, and claims 100
percent coverage for immunisation against diphtheria, pertussis
and tetanus (DPT) in contrast to WHO and UNICEF estimates of 82
percent and 87 percent respectively.
Hoffs endorsement of the governments inflated vaccination
claims help cover up its politicisation of this fundamental form of
healthcare. More to the point, though Hoff may not know it given
her lack of medical expertise, if national coverage rates had really

been as high before the conflict as she and the Assad

government insist, polio would never have re-appeared in 2013.
That is because the spread of polio requires herd immunity the
protection conferred on the whole population when immunisation
coverage reaches a critical threshold - to drop below 80-86
percent. It would take well over three years for herd immunity to
drop from 99 percent to anywhere approaching this level,
particularly given the concomitant drop in the crude birth rate
and fertility.
Moreover, Hoff associates the risk of polio and other crippling and
deadly diseases to unvaccinated children with the conflict. This
rationalisation that polio is the result of conflict - reflected as well
in WHOs 2014 report Polio: War in Syria opens the door to an old
enemy - is often repeated by the Syrian government. But
blaming conflict by itself is lazy, and wrong.
Polio did not reappear in Iraq throughout the entire eight years of
the Iraq war (2003-2011), yet broke out in Syria after a mere two
years of war - and then spread to Iraq, almost certainly as a result
of the forced displacement of civilians from northeastern Syria.

In August 2014, displaced Iraqis who fled fighting between Islamic

State and Iraqi Kurdish fighters in the Mosul and Anbar regions
receive polio vaccines from a health worker at a mosque near
Basra (AFP)
Polios re-emergence in Syria is consistent with pre-existing low
immunisation rates and the vulnerability of Syrian children living
in government-shunned areas such as Deir Ezzor, Aleppo and
other northern governorates.
All cases of polio in Syria broke out in areas that had long been
opposed to the Assad regime, reflecting the political dimension of
the outbreak.
Not a single case occurred in territory controlled by the
government. In Deir Ezzor, where polio first re-appeared in 2013,
polio vaccination coverage had dropped to 36 percent. This was a
man-made outbreak. Hoff ignored all of this.
Polio cover-up
When polio did reappear in July 2013, the Syrian Ministry of
Health hid it for months, insisting that its Early Warning Alert and

Response System, set up in September 2012 with the technical

help and sole financial support of WHO, was reliable.
Then, in the first week of October 2013, samples from a cluster of
crippled children in Deir Ezzor smuggled cross-border for analysis
in Turkey were also sent to the National Lab in Damascus.
Damascus first insisted that the samples were contaminated, then
that they showed Guillain-Barre syndrome, even though this
syndrome is determined by clinical diagnosis, not by a laboratory
test.
Hoffs claim that polio was 're-eradicated thanks to concerted
efforts by WHO and UNICEF' is a breathtakingly outrageous
attempt to rewrite history
Only in October 2013, did the Syrian Health Ministry concede that
an outbreak of polio was underway after undeniable laboratory
proof was provided through the coordinated efforts of
doctors working inside conflict areas, the opposition-supported
Assistance Coordination Unit (ACU), the Turkish government, and
the US Centers for Disease Control (CDC).
Hoffs claim that polio was re-eradicated thanks to concerted
efforts by WHO and UNICEF is a breathtakingly outrageous
attempt to rewrite history and take credit where none is due.
In fact, as noted, WHO had nothing to do with the discovery or
containment of the polio outbreak, toeing the government
line during the critical early stages of the polio outbreak, denying
the re-emergence of polio for months, and endorsing the
governments surveillance system as it failed to detect the
outbreak.
Only after independent proof made denial impossible did WHO
finally acknowledged polios reappearance in Syria on 29 October
2013, the day after the Syrian Health Ministry did.
As for containing the polio outbreak, credit belongs to the
independent Polio Control Task Force (PCTF), a group of Syrian
and international health NGOs formed to address the polio

emergency in the absence of effective government, with a

network of 8,000 volunteers across northern governorates.
It was supported by the Turkish government, which helped it to
purchase vaccines independently of WHO and its UN sister
organisation, UNICEF. Without WHOs or UNICEFs assistance, the
PCTF vaccinated 1.4 million children over the course of eight
separate vaccination campaigns conducted in seven
governorates, achieving a coverage rate of 92 percent. That
stopped polio in its tracks.
The PCTF was supported in this effort not by WHO or UNICEF,
which the Syrian government prohibited from taking part, but by
the International Rescue Committee (IRC), the International
Medical Corps (IMC), and the Turkish and French governments.
Hoffs self-congratulation for a campaign that WHO was barred
from supporting by the same government that created the
conditions that made polios return possible, also fails to mention
the many medical staff and volunteers who lost their lives during
this vaccination campaign as a result of the targeted air strikes of
the Assad regimes air force.
READ: WHO's response to Dr Annie Sparrow's piece on its work in
Syria
Further, WHOs reliance on the governments limited and
politicised public health surveillance and reporting extends
beyond polio.
Killing medics, bombing hospitals
In Cholera in the time of war, published by the British Medical
Journal of Global Health in October 2016, my colleagues and I
describe similar problems with respect to cholera - another
disease that reflects both the pre-war neglect and the subsequent
deliberate war-time destruction of the public health system in
opposition areas.

The Syrian government suppressed most information about a

cholera epidemic that broke out in 2009 as well as cholera deaths
of several children that occurred in October 2015.
The second troubling aspect of Hoffs testimony in November
concerns her mention of the repeated attacks on healthcare
facilities in Syria.
Of the 768 medics killed during this period as documented by
PHR, 713 were killed by the Syrian and Russian government
forces
She cited a figure of 126 such attacks between January and
September 2016, yet fails to note that the chief perpetrator of
these attacks was the Syrian regime, joined by its Russian ally.
According to Physicians for Human Rights (PHR), of some 400
attacks on 276 separate healthcare facilities between March 2011
and July 2016, Syrian and Russian forces have been
responsible for more than 90 percent.

Men fish in a river in the eastern Syrian town of Deir Ezzor in

February 2014 (AFP)
Of the 768 medics killed during this period as documented by
PHR, 713 (almost 93 percent) were killed by the Syrian and
Russian government forces.

These attacks parallel the governments targeting of civilians in

opposition-held areas, where roughly seven million civilians live.
From 1 August to 30 November 2016, the Syrian American
Medical Society (SAMS) documented 112 additional attacks on
health facilities of which 111 were committed by pro-regime
forces. These attacks are included in a SAMS report released
earlier this month.
Since August, at least another 29 healthcare workers have been
killed, as documented by the Syrian Network for Human Rights,
bringing the total to 797, of which 742 (93 percent) were killed
on duty - by pro-regime air strikes.
Hoff again failed in her testimony to mention any of this.
See no evil, speak no evil
Beyond refusing to name the perpetrators of these attacks, Hoff
clouded the issue by describing the militarisation of healthcare
facilities by several parties to the conflict as another visible
violation, as is the targeting of medical personnel.
Insofar as such militarisation exists, it is an insignificant problem
compared with the Syrian and Russian governments targeting of
health facilities where there was no militarisation in sight.
FSA, Ahrar al-Sham, and even Jabhat al-Nusra have requested
that hospitals not be built anywhere near their military bases, as
they do not want to suffer from regime strikes
Indeed, Syrian doctors who have been in contact with non-state
military groups such as the Free Syrian Army, Ahrar al-Sham, and
even Jabhat al-Nusra told me that these groups have requested
that hospitals not be built anywhere near their military bases, as
they do not want to suffer the collateral damage when the
hospitals are targeted by the Syrian air force.
It is typical that Hoffs testimony, given less than 24 hours
after the last trauma hospitals in eastern Aleppo were destroyed
by targeted Syrian and Russian air strikes, including the only

pediatric hospital, makes no mention of these attacks, or of the

civilians killed.
Hoff also failed to describe the consequences of these incessant
air strikes on health facilities.
For example, Hoff noted without specification that pregnant
women do not have access to safe delivery, but pregnant women
in government cities such as Damascus, Tartous, Sweida, Lattakia,
Quneitra do have access to safe delivery, obstetricians and blood
transfusions.

A Syrian woman takes care of her husband at the last functioning

hospital as people wait to be evacuated on 18 December 2016 in
the last rebel-held pocket of Syria's Aleppo (AFP)
It is only in opposition-held areas that healthcare is compromised
because of the damage and destruction resulting from air strikes
by pro-government forces.

In Eastern Ghouta, for example, home to 450,000 civilians, almost

600 babies are born each month, yet there are only a few
obstetricians.
Meanwhile, the attacks on hospitals make it too dangerous for
pregnant women to spend hours there as they undergo normal
labour. Instead, they must have Caesarean sections. The rate for
C-sections in heavily targeted areas such as eastern Aleppo (until
its fall) and Eastern Ghouta, according to data collected by
physicians that I have spoken with and corroborated by SAMS, has
been 60 to 70 percent.
This is more than double the US average for low-risk Caesarian
sections of 26 percent.
Never name the violator
Hoff stated that WHO condemns attacks on health care in the
strongest terms, yet WHO Syria failed to report any attacks until
2016, and even now fails to say who is responsible.
The sole exception was in March 2015, three years after the
regime had begun its systematic assaults on healthcare in
politically unsympathetic territory, when Hoff reported on not a
Syrian attack but a single attack by US-led coalition forces in Deir
Ezzor.
WHO subsidies also free up Syrian defence ministry funds,
enabling them to be used to finance the targeting of hospitals and
civilian infrastructure
Nor did she explain that that particular attack targeted a wing of a
hospital that had been taken over by Islamic State (IS)
combatants for military purposes.
It is absurd to complain before the UN Security Council, as Hoff
did, that our repeated calls for protecting healthcare, facilities
and personnel always fall on deaf ears when, apart from the case
noted involving non-Syrian forces, WHO never names the violator.

To be fair, this is a policy adopted not only at Hoffs level but also
by WHO headquarters in Geneva.
These obfuscations and euphemisms are of special concern
because health is one of the few areas where it should be possible
to gather a global consensus, even amidst the politics of an
armed conflict.
For example, smallpox was eradicated by many states working
together, with WHOs leadership. But the Syrian government,
rather than demonstrating concern about the health of its
citizens, uses disease and deprivation as a war-crime element of
its war strategy, as WHO surely knows by now, even if it is at
pains not to acknowledge it publically.
Complicit in cover-up
It's not just that WHO covers up for the Syrian governments
medical misdeeds; it is actively complicit in them.
"Blood and war," an article I recently co-authored, showed that
WHO Syria had serially lied to donors and the media about its
subsidising of the Ministry of Defence between 2014 and 2016 by
buying for it millions of dollars of blood transfusion kits, screening
tests for blood-borne diseases such as HIV, Hepatitis B and C, and
hardware.
The effect is not simply to place control of these essential lifesaving goods in the hands of an institution that has a long history
of ignoring humanitarian principles, and withholding safe blood
transfusion not just from wounded opposition soldiers, but also
from the tens of thousands of civilians injured each month in
eastern Aleppo, Ghouta, and other rebel-held areas.
These subsidies also free up defence ministry funds that would
have been spent on these blood-related needs, enabling them to
be used to finance the targeting of hospitals and civilian
infrastructure, and the incarceration and torture ofdoctors - in
short, the undermining of WHOs ostensible public-health
priorities.

The following are images of correspondence last March between

Hoff and Major-General Dr Osama Jamil Ahmad, a military official
third in command at the Ministry of Defense, and head of the
governments National Blood Bank, which is controlled by the
Ministry of Defense:

Three months later, on 14 June, Major-General Ahmad presented

Hoff - who was not present - with this plaque at a ceremony at the
Blood Bank in Damascus on the occasion of World Blood Donor
Day.

A plaque inscribed to Hoff in appreciation of her efforts presented

in a ceremony in June 2016 (SANA)
Translation of wording on plaque: The General Establishment for
Blood and Medical Industries; World Blood Donor Day 14 June
2016; Thank you and appreciation; Ms Elizabeth Hoff, WHO

Regional Representative; For her efforts to develop and support

the institution
Soft pedalling on sieges
The third problematic area of Hoffs testimony concerns
humanitarian access.
In this case, Hoff may be congratulated, as she did accuse the
government by name of withholding approval for the delivery of
surgical and medical supplies to hard-to-reach and besieged
locations.
However, she failed to explain that these politically neutral terms
are euphemisms for opposition-controlled territory, and so avoids
highlighting the political dimension of the aid blockages, or
the responsibility of the government for 98 percent of the more
than one million people forced to live in an area under siege (until
the fall of Aleppo, 1.3 million people).
WHO's Hoff refrained from mentioning the massacre in Hass in
November by pro-government forces, which targeted five schools
with carefully placed bombs, killing 22 children and six teachers
Similarly, while drawing attention to eastern Aleppo as the most
visible face of Syrias suffering, Hoff did not mention that the
relentless air strikes by Syrian and Russian forces using missiles,
barrel bombs, bunker busters, and rockets - put eastern Aleppos
last eight hospitals out of action in November.
Nor did she mention the cluster munitions and other illegal
weapons including chemical bombs used by government forces to
target eastern Aleppo civilians.
Yet she did draw attention to a single mortar attack by rebel
forces on a school in western Aleppo, resulting in six casualties.
She claimed in that case that scores of children were killed or
injured while refraining from mentioning the massacre in Hass in
November by pro-government forces, which targeted five schools

with carefully placed bombs, killing 22 children, six teachers, and

11 other civilians.
One of my colleagues, Dr Khaled Alaji, placed 90 chest drains in
children with blood-filled lungs that day.
Spin and truth of blocked aid
When Hoff described WHOs humanitarian role, it was filled with
vagueness and obfuscation.
Hoff stated that WHO has delivered over nine million medical
treatments throughout Syria and that WHO along with its UN
partners reached all besieged areas for the first time in several
years.
If Hoff were not spinning so positively, she might have noted that
it took several years before the Syrian government granted
permission to reach all besieged areas even once.
Hoff was vocal about WHOs delivery of over nine million medical
treatments but notably silent about what WHO actually
delivered.
In fact, according to minutes of relevant meetings that I have
seen which are not made publicly available, WHO stockpiled 90
tonnes of treatments in government-held western Aleppo, as it
was never given permission to deliver them to eastern Aleppo.
Sometimes it was reduced to delivering boxes of non-essential
items like lice shampoo, given the Syrian governments repeated
denial of approval for life-saving medicine and equipment to
reach those desperately in need.
WHO stockpiled 90 tonnes of treatments in government-held
western Aleppo, as it was never given permission to deliver them
to eastern Aleppo
Hoff ended with several pleas to the UN Security Council which at
first seem illogical until seen in the context of WHOs complicity
with the Syrian government:

The first asked not for the cessation of air strikes on hospitals, but
to please approve a system where all parties have the
coordinates of all convoys and health facilities, and all attacks are
registered.
The second asked not for the lifting of the sieges against more
than one million civilians, but for support of sustained,
unconditional access to all besieged and hard-to-reach locations.
The third, quite rightly, asked for help in allowing critically ill
patients and families to evacuate.
Perhaps she was thinking of the conjoined twins from Eastern
Ghouta, born in July, who after great pressure were permitted to
be evacuated to Damascus, but were denied safe passage out of
the country for critical surgical separation offered by accredited
centres in the US, Germany and Saudi Arabia, all-expenses paid.
Instead, the Syrian government apparently preferred to try to play
the hero by separating the twins itself despite a lack of expertise.
The sudden death of the twins was officially reported as due to
heart failure, a diagnosis clinically incompatible with the twins
condition at the time.
WHOs failure to correct this diagnosis, request a port-mortem, let
alone push for international evacuation, instead blaming the
parents begs the question did WHO help cover up the reason for
the twins death, after what in all likelihood was a botched
surgical separation?
Convoys of shampoo and shrouds
With this disturbing record as an apologist for the Syrian
governments atrocities, if not an active accomplice, it is no
surprise that so many Syrians in both government territory and
opposition-held areas have lost confidence in WHO.
As Dr Monzer, director of health in Idlib, said: We dont need their
convoys of shampoo and shrouds. It would be enough if they
stopped supporting a regime that sends missiles and chemical
bombs.

Given Hoffs recent public thanks to Russia for providing

emergency primary healthcare to some civilians forced to flee
from Aleppo after Russia helped to destroy all the hospitals
there it is hard to have any faith in Hoffs version, as WHO
representative for Syria, of the Syrian public health catastrophe,
her competence in addressing it, much less WHOs alleged
respect for the humanitarian principles of impartiality, neutrality
and humanity.
- Dr Annie Sparrow is Assistant Professor at the Arnhold Global
Health Institute at the Icahn School of Medicine at Mount Sinai
Hospital in New York City.
The views expressed in this article belong to the author and do
not necessarily reflect the editorial policy of Middle East Eye.
Photo credit: AFP
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