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Civil war, contested sovereignty and the limits of global health partnerships: A case study of the Syrian polio outbreak in 2013

Tuesday, 16th of May 2017

Civil war, contested sovereignty and the limits of global health partnerships: A case study of the Syrian polio outbreak in 2013 

Jonathan Kennedy, Domna Michailidou

Health Policy Plan (2017) 32 (5): 690-698.

 

Excerpt below; full text is at https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czw148

 

Published: 

15 February 2017

Abstract

States and the World Health Organization (WHO), an international organization that is mandated to respect the sovereignty of its member states, are still the leading actors in global health. This paper explores how this discrepancy inhibits the ability of glo al case, the polio outbreak in Syria in 2013, analysing a variety of qualitative data—twenty bal health partnerships to implement programmes in conflict-affected areas that are under the de facto control of rebel organizations. We concentrate on a single cruci semi-structured interviews with key actors, official documents, and media reports—in order to investigate the events that preceded and followed this event. The WHOs mandate to respect the Syrian governments sovereignty inhibited its ability to prevent, identify and contain the outbreak because the Assad regime refused it permission to operate in rebel-controlled areas. The polio outbreak was identified and contained by organizations operating outside the United Nations (UN) system that disregarded the Syrian governments sovereignty claims and cooperated with the militants. Thus, we identify a serious problem with so-called global health partnerships in which nation states and international organizations remain key actors. Such initiatives function well in situations where there is a capable state that is concerned with the welfare of its citizens and has exclusivity of jurisdiction over its territory. But they can encounter difficulties in areas where rebels challenge the states sovereignty. Although the response to the Syrian polio outbreak was ultimately effective, it was reactive, ad hoc, slow and relied on personnel who had little experience. Global health partnerships would be more effective in conflict-affected areas if they put in place proactive and institutionalized plans to implement their programmes in regions outside government control.

 

Key Messages

• The WHOs mandate to respect the Syrian governments sovereignty inhibited its ability to prevent, identify and contain the polio outbreak in Syria in 2013.
• The polio outbreak was identified and contained by organizations that disregarded the Syrian governments sovereignty claims and cooperated with the militants. Although these organizations were ultimately effective, they were reactive, ad hoc, slow and relied on with limited experience personnel.
• Global health partnerships would benefit from putting in place proactive and institutionalized plans to implement their programmes in conflict-affect areas that are outside government control.

According to the most recent data, there were 39 ongoing civil wars in the world in 2014, the highest number since 1999, and these conflicts caused the largest annual number of deaths since the end of the Cold War (Themnér and Wallensteen 2015). It is widely acknowledged that intrastate conflicts pose major problems for public health: they divert resources away from healthcare, destroy healthcare infrastructure, and lead to forced migration into crowded and unsanitary conditions (Ghobarah et al. 2004). This paper considers a question that has been largely overlooked by public health scholars: How does the situation of contested sovereignty that arises in rebel-controlled areas affect the ability of global health actors to implement public health programmes? We analyse this issue by focussing on the events preceding and following the polio outbreak that occurred in opposition-controlled areas of Syria in 2013.

The article proceeds as follows. The rest of this section sets out how the current international-cum-global health system, in which national governments and international organizations remain key actors, is ill-suited to implementing public health programmes in areas controlled by militant groups that challenge the sovereignty of incumbent state. The second section discusses methods and case selection. Third, we analyse a variety of qualitative data to demonstrate that the Syrian government and WHO failed to prevent, detect or contain the polio outbreak that occurred in Syria in 2013. Rather, the polio outbreak was detected and contained by a variety of organizations that disregarded the Assad regimes sovereignty claims and cooperated with the rebels. We conclude by considering the policy implication of our analysis.