by Adrienne Fricke, Valerie Dobiesz, Rahaf Safi, Bharathi Radhakrishnan, Timothy Erickson and Phuong Pham*
Abstract: Political identity in armed conflict can significantly impact access to basic state services. In Syria, access to higher education has been restricted, denied, or, in some cases, resulted in physical danger for individuals criticizing the regime and for those suspected of disloyalty. Journalists and NGOs have documented how, since 2011, the state conferred opposition identity on healthcare workers providing patient services to injured civilian protestors. Effectively, the provision of medical services has become “militarized.” In 2019, researchers from the Harvard Humanitarian Initiative (HHI) conducted qualitative interviews with health educators, administrators, and students in northwest Syria and observed a trend of reports documenting restricted access to official medical and nursing programs due to political identity. Facing a shortage of healthcare providers in opposition areas, educators developed alternate teaching institutions for medical and nursing students. These efforts, unrecognized by the state, directly align with the United Nations Sustainable Development Goal 4 to “ensure inclusive and equitable quality education,” even in war-affected settings, with policy implications for the international community.
Mass peaceful demonstrations demanding political change in Syria began in March 2011. Syria’s President, Bashar Al-Assad, rapidly employed the political identity of protestors to justify violence against them. The regime created a strict binary identity: those who are “with the regime” and were unharmed by state violence, and those who “oppose the regime” and were targeted. As discussed below, in time this binary became conflated with religious identity. Eight years later, multiple competing foreign entities have entered the conflict, reinforcing this polarization in a complex narrative that lies outside the scope of this brief but merits further scholarly attention.
Sustained fighting has led to the displacement of over half of the pre-war population of twenty-two million. Approximately six million Syrians have fled to neighbouring countries, while a similar number are displaced internally throughout Syria.[1] In this context, the regime’s well-documented attack on healthcare facilities and personnel has deeply impacted civilian populations, particularly in opposition-held areas.[2]
The Harvard Humanitarian Initiative (HHI) study, in which researchers conducted qualitative interviews with health educators, administrators, and students in northwest Syria, was designed to collect information about the needs, priorities, challenges, and successes of educational initiatives created in response to conflict conditions. Respondent groups included students, educators, and administrators at alternative medical and nursing institutions. Programmesrepresented include the Free Aleppo University (FAU); FAU’s nursing affiliate, the Omar Ibn Abdelaziz Nursing Program; and the Syrian Board of Medical Specialties (SBOMS) residency programme. A bilingual member of the interdisciplinary team at the Harvard Humanitarian Initiative (HHI) conducted remote interviews in Syrian Arabic with respondents in northwest Syria using a survey to assess the impact of war on healthcare education in April and May 2019.[3] The purposive sample included respondents in opposition-held territory in Idlib and Aleppo because these areas sustained heavy aerial bombardment.
The central research question of this study is how conflict affects the teaching and learning of medicine and nursing. The findings indicate that two primary factors influenced access to official health education programmes, in addition to triggering state violence in the form of beatings, detention, and torture. The first was whether the respondents’ chose to identify as protesters; the second was the nearly automatic imposition of an anti-regime identity by the regime on healthcare workers based on their status as providers, and their real or perceived involvement in treating opposition members. Consequently, Syrian medical and nursing personnel residing outside of regime-held areas created an alternative medical and nursing education system to provide opportunities for young people to become healthcare providers. These findings demonstrate the potential policy impact of political identity on access to higher education, and the attendant effect on access to medical services in contravention of United Nations (UN) mandates.
Political Identities and the Syrian Context
As identity scholar Christopher Phillips has detailed, academic debate rages over the nature of political identity in the Middle East.[4] He notes that while the conflict in Syria is commonly described as sectarian, references to sect by all parties to the conflict have developed in a complex political, social, economic, and ethnic context.[5] He outlines how religious “sub-state” identities developed over time in parallel with the Syrian national discourse, noting that “[s]ectarianism has been deliberately and subconsciously encouraged by elites as a ruling strategy… alongside a successful attempt to promote a sense of Syrian national identity.”[6] Phillips argues that structural shifts, such as the collapse of the regime in certain areas, allowed a variety of political responses by local elites, with some embracing an inclusive Syrian national identity and others employing an ethnic or sectarian discourse. He therefore asserts that the conflict is only “semi-sectarian” because of “multiple other fault lines of contention, notably class, ideology and… sub-state ties.”[7] The findings from this study suggest that an additional ‘fault line of contention’ applies: the status of being a healthcare provider or medical/nursing student, as discussed below.
Access to Higher Education in Syria: The Role of Identity
In wartime Syria, the political binary of being either anti- or pro-regime can impact survival, with populations in opposition-held areas subject to airstrikes and sieges. However, residing in such areas does not always correlate to political affiliation. Regime-area critics faced with the decision of security or liberty may feel forced to live in regime-held areas to protect their families. Native residents of besieged Aleppo and Idlib may not have professed loyalty to either side, but were caught in geographic polarization. The imposition of political identity on the basis of geography falsely assumes equal opportunity of choice.
“I could not leave the hospital because it would be looted, but if I stayed in it the regime would consider me an enemy. I decided to stay in the hospital to take care of it and its machines and the operations. The staff who stayed with me, we stayed together. All of us were seen as enemies. We could no longer visit our families” (SYNU01, Male, Nursing Educator).
Moreover, when students were displaced by violence to opposition-held areas, they lost access to regime-controlled institutions. Students also described how previous political protest restricted their access to education:
“[W]e were a part of the revolution, so it is not possible for us to go back to the regime even though we were the lowest resisters” (SYME12, Female, Medical Student).
In response to the provider gap, Aleppo University faculty and administrators critical of the regime founded the Free Aleppo University (FAU). FAU “started [as a result of] the number of students displaced to a certain area because of their opposition to the regime,” including “students in their first and second year of medical school, [and] some who just graduated high school” (SYME06, Male, Educator). A student explained, “[W]hen I was studying the baccalaureate [the final high school examination], there were no universities, so when [the FAU] opened [in the opposition-held area], it was a window of hope for a lot of students – not just me” (SYME12, Female, Student).
Political identity also foreclosed opportunities for medical residents – graduates of medical schools hoping to specialize – in much-needed areas, notably in trauma surgery and obstetrics and gynaecology. Consequently, “a large number of doctors [were prevented] from specializing in residency programs. It is because of [fear of] arrest…. [M]ost residents moved from accredited hospitals in regime-controlled areas to continue their training in field hospitals that are not accredited” (SYME04, Male, Faculty). A resident indicated that “Before the conflict… we were all enrolled in [official] programs… the regime chasing us required us to go to areas that did not have programs. These programs were established because we were no longer able to access education [in] regime-controlled areas” (SYME17, Male, Resident).
Some prospective students reportedly moved to regime-controlled areas because they were unsure of the quality of the FAU program. One student explained, “[T]his was still a new program, and they believed it would not be able to provide the necessary medical education” (SYME 02, Male, Medical Student). This indicates that some individuals, whose identities were presumably not clearly known to regime agents, retained physical and academic mobility. Accreditation, or government recognition of an institution’s legal authority to grant degrees, is extended to regime-area programmes. Enrolment in accredited programs in regime territory was functionally impossible, however, where intelligence actors knew or believed medical students and residents had anti-regime affiliations. This group risked arbitrary arrest and forced disappearances, tactics commonly employed by the regime against critics and healthcare workers, alike.
Healthcare facilities and healthcare providers have been directly targeted; observers have documented at least 583 attacks on health facilities since 2011.[8] An administrator explained that “the hospital might at any point be targeted through airstrikes or destruction.” (SYME04, Male). Critically, the Syrian government considers healthcare workers providing patient services to injured civilian protestors, including medical and nursing faculty and students, “terrorists.”[9] When medical residents treat patients who are anti-regime, their individual political identity is reduced to that of their patient. “When I was working on my residency [in] regime areas, I was filled with fear from the possibility of being arrested because I was treating protesters, so I was a target” (SYME17, Male, Resident). In this way, providing care in a neutral and unbiased manner results in the assignment of an anti-regime identity, and the consequences this may entail.
Conclusion
Collective and individual political identity can impact access to key services in armed conflict settings, as in Syria. While much analysis of Syria focuses on sectarian dimensions of political identity, a focus on the geographic and ideological dimensions of identity is necessary to inform robust policy decisions. HHI’s study finds that medical and nursing students who had taken part in the peaceful opposition to the regime, as well as those residing in opposition-held areas, or treating patients deemed to be anti-regime, faced physical insecurity and other barriers to accessing higher education, particularly in opposition-held areas.[10]
Efforts in northwest Syria to promote equal access to medical and nursing education demonstrate that local actors can develop programmes aligned with the aims embodied in the UN Sustainable Development Goals (SDGs). The fourth goal (SDG 4) is particularly relevant to the findings of this study: “[e]nsure inclusive and equitable quality education and promote lifelong learning opportunities for all.” A critical target to achieve this broader goal is to “ensure equal access for all women and men to affordable and quality technical, vocational and tertiary education, including university” (SDG Target 4.3).[11] Policymakers should explore practical aspects of political identity to understand how to promote access to higher education in medicine and nursing during conflict.
The findings from this study have greater implications for the Middle East and the international community as regards access to education in conflict-affected settings. Discussions about implementation of the SDGs have been widespread since the 2016 World Humanitarian Summit, and the international community is increasingly aware of higher education’s value in promoting long-term positive outcomes for vulnerable populations. Local educators’ endeavours to provide equal access to medical and nursing education, and the role identity plays in determining access, merit further study by humanitarian actors, including UN partners, donors, and governments.
*Adrienne Fricke is a visiting Scientist at the Harvard School of Public Health and Fellow at the Harvard Humanitarian Initiative.
Valerie Dobiesz is a Core Faculty Member of the Harvard Humanitarian Initiative and Assistant Professor of Emergency Medicine at Bringham and Women’s Hospital.
Rahaf Safi is reading for a Masters in Public Policy at the Harvard Kennedy School of Government.
Bharathi Radhakrishnan is a Post-Doctoral Student at the Harvard Humanitarian Initiative.
Timothy Erickson is a Core Faculty Member of the Harvard Humanitarian Initiative and Associate Professor of Emergency Medicine at Bringham and Women’s Hospital.
Phuong Pham is an Assistant at the Department of Global Health and Population and Harvard School of Public Health and Director of Evaluation and Implementation Science at the Harvard Humanitarian Initiative.
Notes:
[1] UNHCR and the Government of Turkey, “Syria Regional Refugee Response,” Operational Portal Refugee Situations, 2019, https://data2.unhcr.org/en/situations/syria, retrieved November 21, 2019; Internal Displacement Monitoring Centre, “Syria,” Country Information, 2019, http://www.internal-displacement.org/countries/syria, retrieved November 21, 2019.
[2] Physicians for Human Rights, “The Syrian Conflict: Eight Years of Devastation and Destruction of the Health System,” March 12, 2019, https://phr.org/our- work/resources/the-syrian-conflict-eight-years-of-devastation-and destruction-of-the- health-system/, retrieved November 21, 2019.
[3] Since December 1, 2019, the Syrian government has pursued an offensive in northwest Syria, resulting in the displacement of more than 900,000 people according to UN Special Envoy Geir Pedersen. See “Briefing to the Security Council by UN Special Envoy Geir O. Pedersen,” February 19, 2020, https://www.unog.ch/unog/website/news_media.nsf/(httpNewsByYear_en)/2929AC05879D40A3C1258513006157C4?OpenDocument.The UN Under-Secretary for Humanitarian Affairs and Emergency Relief Coordinator, Mark Lowcock, has noted that violence in northwest Syria has severely damaged civilian targets including health facilities, many of which have been closed. See “Statement on Northwest Syria,” February 17, 2020, https://reliefweb.int/sites/reliefweb.int/files/resources/Statement%20on%20Northwest%20Syria.pdf.)
[4] Christopher Phillips, “Sectarianism and conflict in Syria,” Third World Quarterly 36 (2015):357-76.
[5] Ibid, 371.
[6] Ibid, 362.
[7] Phillips, “Sectarianism and conflict in Syria,” 357.
[8] Physicians for Human Rights, “Illegal Attacks on Health Care in Syria,” http://syriamap.phr.org/#/en.
[9] Security forces tortured and killed medical students who had tried to smuggle painkillers through a checkpoint. The security forces then asked their fellow students to collect their corpses, which had holes in their foreheads, tongues and eyes “from a power drill.” Jack Ewing and Karam Shoumali, “Where Doctors are Criminals,” New York Times, December 21, 2019. Available athttps://www.nytimes.com/2019/12/20/world/middleeast/syria-medical-criminalization.html, retrieved February 20, 2020. See also Physicians for Human Rights, “’My Only Crime Was That I Was a Doctor’, How the Syrian Government Targets Health Workers for Arrest, Detention, and Torture,” December 4, 2019. Available at https://phr.org/our-work/resources/my-only-crime-was-that-i-was-a-doctor/, retrieved 20 February 2020.
[10] The Assad regime is not alone in employing this tactic; respondents reported that local militias allied with the extremist political groups who seized power in Idlib in January 2019 have restricted university access where students do not profess loyalty.
[11] United Nations, “Sustainable Development Goal 4,” Sustainable Development Goals Knowledge Platform, 2019, https://sustainabledevelopment.un.org/sdg4, retrieved 13 November 2019.
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