Healthcare Under ISIS: the Fate of Health in Syria and Daesh’s Governance Dilemma

Aleppo before the Syrian Civil War

Little attention has been paid to healthcare in Syria, where both Daesh and Al-Assad have targeted the health sector as part of their military strategy—with disastrous consequences for civilians. However, alongside this destruction, Daesh has attempted to set up its own healthcare system in order to legitimize itself as a state.

Amidst a surfeit of Islamic State (Daesh) propaganda, one video first posted online in April, 2015 stands out from the rest. Rather than featuring clips of beheaded hostages, it opens with an ambulance. In the video, an Australian doctor named Abu Yusuf discusses the establishment of the health ministry and shows off a well-equipped Raqqa general hospital. The video serves to introduce the ISHS—the IS Health Service—with a name and logo drawn from a cornerstone of the British welfare state, the NHS. Instead of spreading terror, this video aims to present Daesh as a normal state with modern social services. This is just one part of the conundrum that is healthcare in Syria.

For all its importance, little media attention has been paid to the health care catastrophe in Syria, where Daesh and Assad have both intentionally targeted the health sector as part of their military strategies. Yet, health is instrumental to the politics of the conflict. Daesh has recognized that in order to build popular support and demonstrate that it is capable of administering a bureaucracy, the terrorist group must construct a healthcare delivery system. This humanitarian aim is often second to the group’s military and religious goals, compromising Daesh’s ability to win over the hearts and minds of the local populations under the group’s control. The U.S.’s counter-terrorism strategy should exploit this, approaching the fight against Daesh through the lens of governance and development rather than a primarily military strategy.

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In the face of more immediate concerns and more startling headlines, one part of the Syrian conflict that has largely been ignored is the effect of five years of war on the country’s health sector. Health infrastructure has been devastated, and it has become difficult to deliver aid and treat civilians in many areas. According to the Syrian American Medical Society and the WHO, almost 500 healthcare workers have been killed, and more than 50% of all physicians have been forced to flee the country. In Aleppo, a city with a pre-war population of more than three million people, only 300 physicians remain—including only sixteen surgeons. The World Health Organization has reported the resurgence of once-eradicated infectious diseases like polio, as well as the emergence of measles, typhoid, H1N1 and tuberculosis epidemics. Approximately 60% of hospitals and 90% of the local pharmaceutical industry has been destroyed.

Almost all field hospitals lack CT scanners, most have only basic X-ray equipment, and few have intensive care units or ultrasound machines. Aleppo averaged 50-75 war-related trauma cases a day in early 2014, resulting in difficult triage decisions for understaffed hospitals short on equipment and resources. One Aleppo surgeon reports that “if an operation is likely to take more than two hours, we have to forget it and the patient dies.”

Importantly, this destruction has not been accidental. For both the Syrian government and Daesh, targeting health care infrastructure has become a weapon of war to destroy their opponents by preventing care for injured combatants. This strategy has been devastating for doctors and civilians alike. Hospitals have often been the targets of government barrel bombs. In the Aleppo governate, every major field hospital has been bombed multiple times. As a result of these attacks, many patients avoid hospitals. One physician from Aleppo commented that “unless they feel their life is in danger, many people won’t go to hospital because it is targeted for bombardment.”

Health workers are also in danger of facing violence from all sides when they treat patients regardless of which faction they belong to. The U.N. noted that “anti-terrorism laws issued on 2 July 2012 effectively criminalize medical aid to the opposition.” According to a report from the Johns Hopkins School of Public Health, such legislation has resulted in the arrest and killing of medical workers. The report claims that “of the 25 [Syrian doctors] interviewed, six had been arrested and tortured, two of them twice.” Apparently, it is common knowledge that doctors are often tortured more brutally than other prisoners.

The attacks on medical infrastructure and the targeting of doctors represents a significant shift in military tactics from past conflicts, where medical workers were treated as civilians and non-targets—in accordance with international law and the Geneva Convention. Physicians for Human Rights write that in Syria “the symbols of the Red Cross and Red Crescent have been turned from a shield of protection into crosshairs on the backs of those who knowingly risk their lives to save others.”

Daesh’s Bureaucracy and Social Services

While both the Assad regime and Daesh have worked to cripple Syria’s healthcare capacity, Daesh also seeks to legitimize itself as a state with sovereignty over borders and a population. To achieve this, they are seeking to win over the hearts and minds of those it governs—attempting to build popular support. Part of this plan to legitimize itself as a state involves establishing an apparatus for delivering social services to civilians, including healthcare.

To this end, Daesh has created a health department—called diwan al-siha—to oversee health services and establish regulations for smoking and consuming alcohol, amongst other things. Yet, to call this health department a new creation is a bit of a misnomer. Diwan al-siha relies considerably on co-opting the already-existing structures in areas it comes to control. Once control is established in a new area, a notification is generally issued ordering those who worked in health services to return to work under threat of confiscation of their homes.

Still, Daesh manages to oversee a complex bureaucracy and attempts to oversee an egalitarian provision of services. The territory occupied by Daesh in Syria is divided into 13 provinces, and each province has a governor responsible for overseeing local civilian administration, including healthcare programs. While the health department crafts policy, enforcement is within the jurisdiction of each governor. To encourage workers in the public service of the previous government to remain in their positions, Daesh provides workers with a regular salary. However, Daesh militants oversee operations in all governmental facilities and departments.

Daesh’s Conflicting Aims

In the fourth issue of Dabiq, Daesh’s English-language newsletter, the group wrote that a “state cannot be established” unless it looks after both the “worldly and religious needs” of Muslims. Unfortunately, these seem to regularly come into conflict, particularly when it comes to healthcare. Daesh has in interest in convincing local populations that it cares for them and can offer them a high standard of living, but its religious and military goals often supersede the former. Daesh cares much more about the religious life of the population it controls than their material needs.

Slavoj Zizek, in an article in the New York Times, aptly captures what separates Daesh from the society of states that it seeks to join. He writes that “the public statements of the ISIS authorities make it clear that the principal task of state power is not the regulation of the welfare of the state’s population (health, the fight against hunger)—what really matters is religious life and the concern that all public life obey religious laws… Therein resides the gap that separates the notion of power practiced by ISIS from the modern Western notion of what Michel Foucault called ‘biopower’, which regulates life in order to guarantee the general welfare: the ISIS caliphate totally rejects the notion of biopower.”

This subsumption of welfare under religious obedience seems to be the root cause of many of Daesh’s failures in the healthcare sector. Its policy decisions seem largely based on the group’s ideology and desire to consolidate power, leading it to ban the import of medical products from Iran, require all new medical clinics to obtain licenses from the diwan al-siha and insist that female patients can only be treated by female doctors.

The focus on religious obedience over human welfare is apparent, for example, in the way that Daesh treats female doctors. Mohammed Abboud, writing for Al-Akhbar, describes the plight of female doctors in Mosul with this anecdote: “Hamadani shared the story of a colleague specialized in obstetrics and gynecology who was denied access by IS militants to a hospital, where she was scheduled to do a surgery, because she did not wear a veil over her face. When she explained that she needed to examine patients, they replied, with a Mosuli accent, “let the patients die, it is not important, what matters is your veil.””

Similarly, Daesh’s military aims often trump its commitment to providing healthcare for civilians. The majority of benefits from the healthcare system are directed towards fighters rather than local civilians. While Daesh fighters in Raqqa receive free healthcare, civilians must pay exorbitant prices. Private health clinics have been closed and the public hospital in Tel Abyod has open in 2015, but with steep prices. Daesh-only hospitals often have the most advanced technologies and the best doctors.

Evaluating the State of Health under Daesh

Some Daesh Fatwas, previously unpublished but leaked online, provide clues as to the true state of medical care in the regions of Syria and Iraq that the terrorist group controls. Fatwa no. 43 asks: “what is the ruling on the presence of male doctors for women’s illnesses given that there are female doctors specializing in women’s illnesses but few in number?” The response was that the “principle is that the women should go to a female doctor to treat her and she should make an effort to look for that,” but that one could resort to seeing a male doctor in cases of extreme necessity. From this question, it seems clear that health care for women has suffered drastically due to Daesh regulations and the flight of female health professionals, who often face harassment or assault at the hands of Daesh fighters. Fatwa no. 37 states that travel to ‘dar al-kufr’ (the abode of disbelief) is permitted if a medical condition cannot be treated within the caliphate, responding to the question of whether one can travel to “areas of the regime out of need.” From these internal documents, it appears clear that the diwan al-siha cannot be regarded as an improvement in comparison with what existed before. For many Syrians, it is likely a deterioration.

Furthermore, Daesh’s ideology has sparked backlash from female doctors, whose dissatisfaction has in the past endangered Daesh’s ability to administer a health service. In 2014, female doctors in Mosul’s hospital went on strike in protest against the dress code imposed on them by Daesh fighters. This forced the group’s hand, and a compromise was eventually reached. While female staff must still be covered, they can now mingle with male co-workers and patients in order to deliver care. In order to provide health care, it is clear that Daesh will have to give in on some of its ideological aims.

The cost of healthcare in Daesh-controlled territories has expanded and residents are apparently largely displeased with the quality of care they receive. Many Syrians are not used to being charged for such services after decades under the Baath party, which offered free healthcare. Daesh, on the other hand, charges astronomical rates. In al Mayadeen, the cost of a Cesarean birth is 15,000 Syrian pounds—around $ 80—in an economy where the GDP per capita is only $1,700. In short, Daesh is losing the battle of providing social services and gaining the support of local populations.

Healthcare Diplomacy and the Western Response

As much as it claims to be a state like any other, Daesh’s borders are much more porous—indeed, flight and mass migration have become the only option for many in regions under the group’s control. This mass migration may ultimately be a danger for Daesh. If more doctors and other skilled professionals leave, it will undermine Daesh’s capabilities on the battlefield.

Daesh’s ‘citizens’ actually form one of its principal forms of income. Just as Syrians and Iraqis are frustrated with paying exorbitant fees for health care, the costs of paying for other social services—which can sometimes amount to nothing more than extortion—has turned many against Daesh.

This provides an opportunity for the West to weaken and defeat Daesh by aiding and advising local governments and NGOs, and by helping them to outcompete Daesh’s attempts at providing social services. Western governments should focus on providing social services in areas that have been recently re-captured by the coalition fighting the terrorist group. If local populations understand that the defeat of Daesh will mean an improvement in their quality of life, they will be less likely to support Daesh or collaborate with the group. Likewise, Western powers should aim to destroy the belief—put forward in Daesh propaganda—that the group’s health system is functional in order to dissuade international doctors from attempting to enter Syria.

Providing healthcare is also important in envisioning a post-Daesh future for Iraq. The U.S. needs to prepare not only for the defeat of Daesh in Iraq, which appears increasingly weak, but for what will replace Daesh when it falls. Ensuring that reconstruction is smooth and that populations experience an increase in the quality of healthcare will be central in preventing the re-emergence of terrorist threats in the country.

A version of this approach has been attempted against the Taliban in Afghanistan, where prioritizing the governance of towns liberated from the group is recognized as a crucial aspect of preventing insurgents from coming back. In Marja, American and Afghan commanders brought in an Afghan government as police force as soon as shooting stopped. “We want to show people that we can deliver police, and services, and development,” said Lt. General Mohammed Karimi, the Afghan Army’s deputy chief of staff. “We want to convince the Afghans that the government is for them.” A similar approach in Syria and Iraq, focusing on offering health care and turning electricity back on, would be consistent with such a strategy.

White House strategy in the fight against Daesh does currently include significant humanitarian aid. The U.S. has delivered $5.1 billion in food, water, shelter, medical care and warm clothing in Syria and Iraq since the start of the conflict. Yet, the response on the ground has often been lackluster. As coalition forces retook the Sunni stronghold of Fallujah at the end of June, it appeared that refugee aid-planning had largely remained an afterthought. As aid organizations had failed to prepare appropriately, there were only a fifth of the UNHCR camps required, and inadequate provisions of water, food, and shelter. The Washington Post wrote that “The United Nations said the pace of new arrivals caught it off guard, even though tens of thousands of people were known to be trapped in the city before the operation began last month. The Iraqi government, meanwhile, under political pressure to launch an offensive quickly, appears to have prepared little assistance for the fleeing families.”

Clearly, more will be necessary to prevent such humanitarian disasters in cities such as Mosul. This would likely involve further monetary contributions, but it is clear that greater attention to the humanitarian situation and the needs of Iraqi citizens will also be required. In future battles, preparations for assistance must be made further in advance if the Iraqi government is to win the support of the people it is liberating. In short, health and other social services must become a greater priority. Likewise, restoring local government and offering social services must become a priority for both the U.S. and Iraq alongside offering aid to refugees.

If Western powers aim to destroy Daesh and prevent the re-emergence of terrorist groups in the region, more is needed than a simple military strategy. The U.S.-led coalition should use its ability to deliver social services, including healthcare,in re-captured territories in order to win the hearts and minds of those under Daesh control and spark resistance.