The White Helmets, a group of emergency response volunteers, have received international acclaim for their heroic work in the Syrian civil war. On 21 July 2018, approximately 422 White Helmet volunteers and their families were successfully evacuated from Syria by the Israel Defense Forces. Vageesh Jain argues that future evacuations of aid workers at imminent risk would be catastrophic for the health of the Syrian population.

The White Helmets, or Syrian Civil Defence, was formed during the Syrian Civil War as a group of volunteers who work primarily on urban search and rescue in response to bombing, medical evacuation, and essential service delivery. On 21 July 2018, the Israel Defense Forces carried out an operation to evacuate more than 400 of these volunteers and their families from Syria. This was the result of a multilateral decision to resettle these individuals in a number of Western countries including Germany, the United Kingdom, and Canada.

As of April 2018, the White Helmets claim to have saved more than 115,000 lives, losing more than 200 volunteers in the process. The group has consistently made headlines in the West as unsung heroes battling to save people from the tyranny of Assad and his Russian allies. The Syrian regime, on the other hand, has accused the group of faking rescues, reporting non-existent chemical attacks, and having links to terrorist groups. 

The decision to evacuate some of the volunteers to other countries was made on humanitarian grounds. The new UK Foreign Secretary Jeremy Hunt explained, “due to their high profile, we judged that, in these particular circumstances, the volunteers required immediate protection.” On the face of it, this is a commendable act of humanity, and one that has drawn acclaim and relief from many. Although more than 400 White Helmets made it out of Syria, the evacuation was initially planned for 800 and their families. If this one-off decision (to selectively evacuate at-risk aid workers over others) turns into ongoing policy, it may carry significant long-term repercussions for the health of the Syrian population. 

Inconsistent resettlement policies

In 2016, the United Nations High Commissioner for Refugees estimated that out of all Syrian refugees in the Middle East and North Africa region, one in ten would need resettling by 2018. Despite this, the international response to the crisis has been varied, with Germany offering to resettle 20,000 refugees within two years, the UK offering to settle 20,000 in five years, and Canada resettling 46,000 refugees in one year alone.  

Of course, resettlement is not the only available policy option to deal with the refugee crisis. It is well known that although the UK’s resettlement offering may be considered comparatively meagre, the UK is the second largest bilateral aid donor to the crisis.  The UK government has defended its policy on resettlement by advocating for heavier investment to support neighbouring countries, aid agencies, and refugee camps. Why then, when it comes to the White Helmets, are these options not as appealing? 

It would be more consistent with British policy thus far to evacuate the White Helmets to nearby areas, rather than resettle them in the UK. It must be said that neighbouring countries are struggling to cope with the refugee influx, with Jordan now barring refugees from crossing the border. Nonetheless, the jump to resettle these volunteers in the West represents a departure from the general policy trend until now. 

The motivations of Western leaders are said to be humanitarian, but even if this is the case it is selective humanitarianism; there are many more vulnerable in need of resettling. Politically, resettling a group of people perceived to be heroes in grave danger will be more popular with domestic audiences, but populism should not be the benchmark for effective foreign policy.

Foreign policy and global health: A two-way street

A nation’s foreign policy objectives can be furthered through global health partnerships and collaboration. Investment in health programmes can be a soft power tool, if used to improve political reputation, international relations and global perceptions. For example, in 2003 the U.S. president initiated the President’s Emergency Plan for AIDS Relief. This plan began around the time of the Iraq War, clearly meant to improve international perception of the U.S. and promote its role as a responsible global citizen.  

Health can also be improved and promoted through foreign policy. The 2013-2016 West African Ebola outbreak demonstrated that global health security is becoming a foreign policy concern, in an increasingly globalized world. The decision to resettle some White Helmets, however, provides an example of how foreign policy can be detrimental to the long-term public health objectives in the country of intervention. 

Equity in foreign policy

Health has become a central feature in foreign policy partly because of the global move toward social justice. Health is, after all, a human right. The same argument made to support a selective resettlement policy can also be used against it. On the one hand, it can be argued that individuals at high-risk of attack must be protected, as they have a right to life. On the other, selecting a group of volunteers for extraction from a war-zone above other equally desperate civilians in the same area goes against the ideals of equity and social justice, giving a select few the right to health.

Processes established by UNHCR for the vulnerable persons resettlement scheme (VPRS) are being used to identify those White Helmets eligible to come to the UK. The VPRS initially focussed on women at risk, survivors of torture and violence, cases with medical needs, and children. This latter group make up more than a third of the 6.5 million internally displaced people in Syria in 2018.

The concept of relocating the White Helmets using the VPRS therefore hinges on the assertion that they are more vulnerable than the rest of the Syrian population in the same areas. Reports indicate the White Helmets have been attacked by Russia because the UK and the U.S. fund their rescue work. Indeed, there are reports of first responders being specifically targeted, but these reports have existed throughout the war. 

Implications for health in Syria

In the short term, resettling a group of White Helmets will potentially be life saving for the few volunteers and families who are evacuated to safety. But because of the inequitable nature of such a policy, it will likely worsen the health of the vast majority of the Syrian population, particularly if extended to the other aid workers at imminent risk of being targeted. 

First, gradually removing one of the few effective on-the-ground NGOs in Syria (albeit for humanitarian reasons) with years of experience in emergency response will limit ongoing aid efforts, translating into more deaths unless something else is established in its place. 

Second, the resettlement policy preferentially targets volunteers who are likely to be able-bodied and in better health compared to the rest of the population, including those who cannot volunteer such as the elderly, children, disabled and pregnant women. If such a policy were applied to all at-risk emergency volunteers in Syria (who in general are healthy), then the population demographic in these areas would shift. As a proportion of the population, the demand for healthcare services would increase, and the supply would decrease, further stretching already very limited healthcare resources and widening health inequalities in Syria. 

Third, at least four health systems now operate in parallel in Syria, in areas controlled by the government, opposition (Nusra and Free Syrian Army) and Daesh, and in semi-autonomous Kurdish areas. The ‘whole of Syria’ approach, adopted in 2014 to better co-ordinate health activities by more than 100 health responders in three hubs (Damascus, Amman, and Gaziantep), has only been partially effective due to difficulties co-ordinating the response across such a broad range of actors.  As a group, aid workers and volunteers can be considered relatively politically neutral, or at least more motivated to provide charitable service than to further any political agenda. If such individuals are not present in the post-conflict period to facilitate co-ordination and co-operation between different stakeholders, then efforts towards rebuilding the health system will be severely hampered, preventing any progress in improving long-term population health.

Conclusion

The recent decision to resettle at-risk members of the White Helmets, or Syrian Civil Defence, to Western countries appears noble on first glance. But for those who are not White Helmets, such a decision is unjust. It is debateable as to whether the White Helmets are the most vulnerable in Syria, as this decision suggests. Any move towards selectively resettling remaining aid workers at imminent risk in Syria would be catastrophic for the health of the Syrian population. Future foreign policy decisions must acknowledge the impact on health, and implement countermeasures to militate against these. These decisions must consider the health objectives of the wider population as a central feature if they are to deliver positive and sustainable change. 


Vageesh Jain is a junior doctor working in the United Kingdom National Health Service in the academic training programme. He holds a Masters in Public Health and his research interests include global health policy and systems.