Jamal is not yet a teenager. His school closed in 2011, soon after the Syrian revolution turned into an armed conflict, and his father found him a factory job. One day in 2012 as he returned from work there was a battle going on in the main street near his home. Jamal immediately started carrying wounded children smaller than he is to shelter in a mosque. Then Syrian army reinforcements arrived, clearing the streets with gunfire and hitting Jamal in the spine. The youngsters who took him to the hospital advised him to say that “terrorists” had caused his injury. But Jamal did not want to lie — he told the doctors that a soldier had fired the bullet. The doctors told him to shut up and say it was the terrorists. But they treated him anyway.
Syrian hospitals are at the front line of the conflict. Bullet wounds in children’s bodies are regarded as signs of sedition. Security men prowl wards disguised as medical staff; there are checkpoints outside hospitals and snipers on the roofs. Arrest and torture await doctors who treat opposition fighters or demonstrators, instead of handing them over to the security services. [1] Doctors loyal to their jobs or salaries are sometimes targeted for kidnapping by criminal gangs or armed opposition groups. [2] Health workers in conflict zones cannot get to work and vaccination systems are disintegrating — the government reported in March that 36 percent of its hospitals are out of service. [3] Many pharmaceutical factories have been destroyed, leading the World Health Organization to express worry about shortages of life-saving medicines. In opposition-controlled areas, makeshift field hospitals slopping with infections offer crude, agonizing surgical procedures.
Things are worse in areas contested between the government and its revolutionary adversaries. Up to half of Syria’s population — including Jamal’s family — lives in informal urban settlements, relatively poor districts that provided the vanguard for the revolution and now are often battlegrounds. [4] These settlements mostly populated by rural in-migrants are also places where over the past four decades the Baathist state created a new Syria of textile and service industries, with free education, health and social services, and electricity and running water in nearly every home. Syria largely avoided foreign debt on its path to development. Instead, the country amassed “strategic rent” — aid from Iran, and before that from the Soviet Union and Saudi Arabia. Syria traded with these donors its resistance to US hegemony; alternative possible futures for the Palestinians; and a version of the Arab state that was not dependent on Israeli or US guarantees.
Jamal is seeking treatment in a neighboring country. Syria’s health care system, which before the conflict delivered better health outcomes than Saudi Arabia’s, is now too politicized to cope with a child hit by indiscriminate fire. [5] Nonetheless, many of the government’s supporters today have kept their faith that the Syrian state has provided for the people. “Didn’t we give you houses? Didn’t we give you schools? Are you tired of them?” are rhetorical questions sometimes brandished by security men in house-to-house raids or torture centers.
No Longer Free
But the Syrian success story was in trouble before the conflict began. The government was not able to supply productive opportunities for many rural youngsters, many of whom were shipped off to Lebanon’s harsh labor market. Conflicts between factions of the country’s inscrutable elite — rent-seeking bureaucrats and businessmen — generated periodic economic crises that pushed Syria to seek external resources and policy inspiration. [6] The crisis of the past decade prompted a reconsideration of the country’s social welfare system. In 2005, a new “social market” policy encouraged foreign investment and simultaneously cut social welfare provision. The new approach brought in billions of dollars of Arab and Asian investment in construction, banking and tourism, and opened Syria’s producers to competition from countries with less generous welfare systems. As the policy came into effect, Syria’s oil production peaked and three years of mismanaged drought walloped agricultural workers. Refugees from the Syrian countryside arriving in neighboring countries tell stories of unexpectedly low social provisions — of unvaccinated five-year olds and unschooled teenagers. These reports suggest that the service provision in rural areas was deteriorating before the conflict — that the drought-stricken countryside was being de-developed while the center boomed. Or perhaps that the Baathist tale of modern transformation was something of an exaggeration.
Along with the lack of rainfall, the government’s social and economic policy shifts shaped the backdrop to the conflict. Farmers were pushed off the land into cities where industrial workers were being laid off, rents were no longer controlled and Gulf capital fueled feverish markets in land. [7] Government wages and pensions no longer covered basic needs and the security forces had a correspondingly bigger role in maintaining social discipline. The new rich established private hospitals and schools, while government health spending contracted. With the support of the European Union and the World Bank, the government began to outsource health services, and out-of-pocket expenditures on health care increased. [8]
Many international institutions promote a model of health financing that stresses the state’s regulatory role, allowing a retreat from the public financing of health care. Syria’s adaptation of these international models began in 2003, with immediate implications for its small disability sector. In addition to mostly free health care, Syrians with disabilities are entitled to special schooling and cash benefits, provided by the state. Like other authoritarian socialist disability systems, Syria’s did not promote independent living. The system isolated disabled people from everyday social and economic life in special schools or residential institutions. Rehabilitation services — the mix of physiotherapy, social activities and assistance technologies designed to include disabled children and young people in social and economic life and give them the capabilities needed to live independently — were rare, and were mostly provided by local charitable organizations. But as Syria restructured welfare, it also opened up to the international language of disability rights that inspired the UN’s 2006 Convention on the Rights of Persons with Disabilities. Syria ratified the convention in 2009, and the first lady, Asma al-Asad, pushed the language of disability rights through her charitable foundation, the Syria Trust for Development. The rights of persons with disabilities, like women’s and children’s rights, became a resource for reframing the legitimacy of her husband’s government as it withdrew investment from welfare.
Syria’s experiments in “social markets” were intended to shift costs from the state to families and small-scale social actors. This shift involved a reshaping of its constituencies — the security men, bureaucrats, farmers and industrial workers who benefited to varying degrees from Baathist rule. In retrospect, the experiments were catastrophic. The government’s post-conflict budgets have tried to reverse the catastrophe, injecting new resources into the welfare and subsidies systems that helped the Baath Party to maintain social control for so long. [9] This generosity will eventually find its limits, though, and the forces that were prodding Syria toward a shrunken neoliberal private sector will resume their efforts. Syria will probably emerge from its current crisis into a long period of indebtedness, and its health and welfare systems will probably no longer be free.
The Neighbors
What would a debt-laden, post-crisis Syrian health and social system offer Jamal? How could that system help Jamal and his family work out how to bear the heavy financial burdens that war-induced disability has brought them — increased health costs and loss of income? Might Syria’s neighbors, some of which have also undergone protracted conflicts, have found some solutions worth emulating? These questions, which weigh on the mind of every refugee now looking to finance health care in Jordan, Lebanon, Turkey and Iraq, are not easy to answer because the health and social systems of Syria’s neighbors are not at all easy to generalize from. Two neighboring post-conflict systems — Iraq’s and Lebanon’s — are particularly heterogeneous, but each offers some starting points for comparison. In Iraq, there is sobering evidence of the effects of sanctions and drawn-out urban bombardment on health and social systems. In Lebanon, the unique mix of markets and sectarianism provides insights into how privately financed health and social welfare systems operate.
The Red Cross estimates that 150,000 people have been disabled in the course of Iraq’s multiple wars — they make up part of a much wider population of disabled people. [10] Article 32 of Iraq’s 2005 constitution assigns the state the task of rehabilitating and reintegrating the disabled: In practice, responsibility for services to disabled children is scattered among government and charitable associations. [11] And health care, which represents much of the financial burden of disability, suffered terribly during Iraq’s uniquely unfortunate recent history. After Iraq’s defeat in the 1991 Gulf war, its well-funded, high-performance, authoritarian health care system was eviscerated by 13 years of sanctions, which eventually replaced government finances with a cashless Oil for Food system. With the state’s coffers empty, public spending on health care fell to 1 percent of total health spending, foisting nearly all the costs of health care upon families. [12] Under the US-led occupation, health spending saw modest increases. Between 2008 and 2010, as the occupiers withdrew and the Iraqi government sought to garner popular legitimacy, per capita health spending more than doubled, from $118 to $247 ($340 at purchasing power parity). [13] Iraq’s health spending is still well below the global average and disabled people are poor — Celine Cantat, a disability worker in Damascus before Syria’s conflict broke out, commented on the large numbers of disabled Iraqi children who were on the streets there at the time. A 2011 report on child disability financed by the UN Children’s Fund bemoaned the continuing lack of statistics on disability prevalence, the low state benefits (or social salaries) for disabled people, and the way that the state has devolved to NGOs its constitutional responsibility for disability services and their financing. [14]
NGO funding and NGO services are a sign that the state is relinquishing the financial burden of disability care. Families can cope with short-term illnesses using their own resources, but the costs of chronic disease and disability are much harder to privatize. Social institutions have to play a role. Lebanon’s private health and welfare systems illustrate the importance — and the political costs — of giving private institutions responsibility for health and social services. Three quarters of all health spending was in the private sector in 2011, according to World Health Organization data. Private religious associations provided most of the social welfare there, too. Private health and social welfare systems do not necessarily deliver better outcomes: In 2010, Lebanon’s gross national income per capita was more than three times that of Syria, but Lebanon’s child mortality rates and life expectancy were marginally worse. [15]
Under Lebanon’s largely private welfare system, the financial burdens of disability are mostly borne by private individuals and the family. With severely limited public funds, disabled people need to find affiliations and networks outside the state in order to bear the costs of disability. In Lebanon’s uniquely sectarian political system, disabled people often seek assistance from religious institutions. Most institutions providing subsidized health and social care are linked to Lebanon’s officially recognized sects. They fund themselves through international charitable donations or by using their sects’ political clout to colonize the government’s modest welfare budgets. In order to gain access to this subsidized welfare system, poor disabled people and their families often have to invoke their religious identities. As in any private system, resources for poor people are limited. One way of limiting resources for disabled children is to provide services in residential institutions that separate them from family and social life. They are often known as orphanages, not because the children in them are parentless, but because underfunded institutions can limit costs by imposing the drastic condition of family separation on the beneficiaries of their services. In 2003, Lebanon’s privatized welfare system had 32,484 children in residential institutions; in 2004, Syria had 3,904 such children (Syria’s population is more than five times larger than Lebanon’s). [16]
Disabled people in Lebanon’s privatized, confessional welfare system have to negotiate its soup kitchens and emphatic sectarian markers in order to survive. Syrian refugees in Lebanon (there were nearly half a million as of April) sometimes get caught up in this sectarian system of services. Because Syria and Lebanon have a similar ethnic and religious diversity, Syrian refugees can negotiate access to sectarian services by representing themselves as Shi‘i Muslim or Greek Catholic or whatever — in the same way that many disabled Lebanese people must. By forcing disabled and other poor people to invoke sectarian identities for food and medicine, Lebanon’s welfare systems give its confessional system a material basis, a tangibility lacking in many accounts of its curious identity politics.
From Secular to Sectarian
Syrian identity politics is a different matter. Officially, Syria still has a secular constitution and free welfare services. But all that is changing. The government keeps welfare services functioning in government-controlled areas and malfunctioning in contested or opposition-dominated areas. Access to health and social services is being reconfigured around the geography of conflict. This geography has a sectarian dimension, too, as some of Syria’s smaller religious groups are concentrated in areas where there has been less fighting. People from these areas and groups are then seen as constituencies of the regime. Syria’s religious and ethnic diversity is being turned into the basis for sectarianism, with many Syrian and international actors using religious differences to mobilize military support, build political constituencies, and include or exclude people from the state’s protection.
Possible futures for Syrian welfare financing may aggravate tendencies toward sectarian division. The government is facing an economic crisis — although its 2013 budget envisages spending increases, the government may not be able to generate enough revenue to deliver them. [17] The government’s flirtation with neoliberalism reshaped the way civil society organized. It allowed religious organizations, financed by businessmen benefiting from economic change, to flourish. In the run-up to the conflict, over half of Syria’s charitable organizations were Islamic ones, and their beneficiaries were largely Syrians who were looking for new social networks to meet basic needs as the state retreated from welfare provision. [18] Syria’s conflict will make people radically dependent on new social networks for survival.
These transformations have serious consequences for children with disabilities. Disability services need to be comprehensive, to join up accessible education and health care with measures for social and economic inclusion if people with disabilities are to live dignified independent lives. But Syria’s welfare system is fragmenting under multiple pressures. Future state-funded welfare systems are likely to be much more parsimonious, and to impose the draconian targeting methods of Lebanon’s orphanages. Families disoriented and impoverished by disability are likely to seek out new social networks to survive — and these networks are likely to emphasize social differences. International aid agencies are unlikely to step in. With few exceptions, these international agencies invest little in disability — although good disability services are powerful ways to build an inclusive society, they do not offer the quick, decisive impacts that their management consultants promise them elsewhere.
Jamal did not engage in calculations about responsibility for the costs of health care when he went to help the wounded children he encountered in a street battle. Now a refugee, he has personal experience of the region’s health financing dilemmas. He mostly lies in a hospital bed, his big observant eyes set in a round childish face on the cusp of adolescence. He is cool and assured, and his morale is exemplary. Nursing staff say that with the right treatment he could walk again, and he has taken steps with assistive devices. His father, hard-working, poor, shrewd and warm, with old-fashioned country manners still intact after years of city living, is bravely hustling to gather the thousands of dollars that a spinal cord operation will cost, while trying to keep his family fed.
Endnotes
[1] “Torture in Syria’s Hospitals,” The Lancet, November 5, 2011, p. 1606.
[2] UN Human Rights Council, Report of the Independent International Commission of Inquiry on the Syrian Arab Republic, A/HRC/22/59, Geneva, February 5, 2013.
[3] World Health Organization, Situation Report, March 12, 2013, p. 1.
[4] Robert Goulden, “Housing, Inequality and Economic Change in Syria,” British Journal of Middle Eastern Studies 38/2 (August 2011).
[5] UNICEF and Syrian Commission for Family Affairs, Situation Analysis of Childhood Status in Syria (Damascus, 2008), p. 26.
[6] See Volker Perthes, The Political Economy of Syria Under Asad (London: I. B. Tauris, 1995); and Bassam Haddad, “Syria’s State Bourgeoisie: An Organic Backbone for the Regime,” Middle East Critique 21/3 (Fall 2012).
[7] Raymond Hinnebusch, “Syria: From ‘Authoritarian Upgrading’ to Revolution?” International Affairs 88/1 (January 2012).
[8] Kasturi Sen and Waleed al Faisal, “Syria: Neoliberal Reforms in Health Sector Financing: Embedding Unequal Access?” Social Medicine 6/3 (March 2012).
[9] Syria Report, October 26, 2011.
[10] International Committee of the Red Cross, “Iraq: Giving Disabled People a Chance to Live a Normal Life,” October 20, 2011.
[11] Alison Alborz et al, “A Study of Mainstream Education Opportunities for Disabled Children and Youth and Early Childhood Development in Iraq” (London: Council for Assistance to Refugee Academics, London South Bank University, 2011).
[12] According to World Health Organization data available here.
[13] Thamer Kadum Al Hilfi, Riyadh Lafta and Gilbert Burnham, “Health Services in Iraq,” The Lancet, March 13, 2013, p. 946.
[14] Alborz et al, op cit.
[15] UNICEF, State of the World’s Children (New York, 2012), pp. 89-90.
[16] UN Committee on the Rights of the Child, Consideration of Reports Submitted by States Parties Under Article 44 of the Convention: Third Periodic Reports of States Parties Due in 2003, Lebanon, CRC/C/129/Add.7, Geneva, October 25, 2005, p. 60; UNICEF and Syrian Commission for Family Affairs, Situation Analysis of Childhood Status in Syria (Damascus, 2008), p. 138.
[17] Economist Intelligence Unit, Country Report: Syria, March 2013, p. 6.
[18] Line Khatib, “Syria’s Civil Society as a Tool for Regime Legitimacy” in Paul Aarts and Francesco Cavatorta, eds., Civil Society in Syria and Iran: Activism in Authoritarian Contexts (Boulder, CO: Lynne Rienner, 2013), p. 30ff.
