Doctor administering vaccination

*The views expressed herein are those of the author and do not necessarily reflect the views of the United Nations*

By December 2021, people living in humanitarian emergencies had received less than 4 per cent of the 8 billion globally administered doses of the COVID-19 vaccine. As a UN official stated, the "poorest and conflict-affected countries are being left behind." Many without access to the vaccine are among the estimated 50 to 60 million who live under the full control of armed groups or the additional 100 million living in areas where control is contested. In 2020, the ICRC counted 100 armed conflicts around the world involving 60 States and more than 100 non-state armed groups as parties to those conflicts. In 2021 the number of non-international armed conflicts had more than doubled since the early 2000s, from fewer than 30 to over 70.

This blog post will first pick up where Tilman Rodenhäuser and Mathilde Piret left off in their post, and look at what international human rights law and international humanitarian law have to say about vaccination against COVID-19 in territories under the control of non-State armed groups.

Building on the points that Tilman and Mathilde made on the applicability of human rights law to non-State armed groups, it is also relevant to cite the position of the Interagency Standing Committee Policy (IASC) – a longstanding UN forum for humanitarian coordination. It recognizes that "de facto authorities or non-state armed groups that exercise government-like functions and control over territory are increasingly expected to respect international human rights norms and standards when their conduct affects the human rights of individuals under their control."

Under the International Covenant on Economic, Social and Cultural Rights, article 12 enshrines the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. This entails the prevention, treatment, and control of epidemic diseases. In its General Comment 14, the UN Committee on Economic, Social and Cultural Rights has found that this also entails an obligation to "provide immunization against the major infectious diseases occurring in the community." The Human Rights Committee has also found in General Comment 36 that the duty to protect life implies taking "appropriate measures to address the general conditions in society that may give rise to direct threats to life or prevent individuals from enjoying their right to life with dignity." General conditions include the prevalence of life-threatening diseases, such as AIDS, tuberculosis and malaria, and, arguably, COVID-19.

Building next on the idea that persons living under the control of a non-State armed group party to a conflict are affected by the conflict and thus governed by IHL, at least three arguments support an obligation to vaccinate or allow vaccinations. These are based on the fundamental guarantees of common article 3 to the Geneva Conventions applicable in non-international armed conflict.

The first is the obligation of humane treatment of persons taking no active part in hostilities, which includes the humane treatment of civilians living in areas under the control of a non-State armed group party to a conflict. The ICRC's 2016 Commentary on this provision refers to safeguards for health and hygiene and the provision of suitable medical care. A second aspect of the same set of fundamental guarantees in common article 3 is that the wounded and sick shall be collected and cared for. The same ICRC Commentary provides that caring for the sick "may also entail taking preventive measures to ensure the basic health of the population, including vaccinating people against infectious diseases." As a third argument, common article 3 foresees that an impartial humanitarian body may offer its services to the parties, including a non-State armed group party to the conflict. These services can include humanitarian relief, which, in turn, can include the provision of health care. Once the State's consent is obtained, all parties, including non-State armed groups, must allow and facilitate the rapid and unimpeded passage of impartial humanitarian relief for civilians in need. (Humanitarian relief was addressed in some detail during Session 3 of the 2021 Sanremo Roundtable on pandemics, armed conflict, and international humanitarian law.)

A recent article described the range of positions that armed groups have taken on COVID-19, from denying its existence to proactively addressing the pandemic. Although COVID-19 vaccination has taken place in areas under the control of non-State armed groups, this has not been without significant challenges.

By early November 2021, Idlib and other parts of northwest Syria had received more than half a million AstraZeneca and Sinovac vaccine doses. But still only about 1% of the population in Idlib had been fully vaccinated. In the semi-autonomous area of northeast Syria, there were only enough doses for about 2% of the population by October 2021. In at least three areas of Myanmar under the control of distinct non-State armed groups, the Sinovac vaccine has been supplied with assistance from China. In eastern Ukraine and in parts of Georgia not under the control of the government, Russia has provided the Sputnik V vaccine. And in Yemen, the Houthis had agreed to receive 1,000 doses of the COVID-19 vaccine by August 2021, though at present there is no COVID-19 vaccine rollout in governorates they control.

Many of the challenges to vaccination in areas under the control of non-State armed groups are similar to those we see elsewhere in situations of armed conflict (or even outside of armed conflict). As we look at the challenges to COVID-19 vaccination, it is important to underscore a common backdrop in these areas: ongoing violence and significantly weakened health systems. Health facilities in situations of conflict are often damaged or destroyed; supplies are looted; medical personnel are killed, injured, and often forced to flee. Ongoing fighting, difficult terrain, and frequent bureaucratic impediments can impede access to areas under the control of non-State armed groups – and more generally to areas of armed conflict.

The challenge of providing medical care in armed conflict was the topic of the UN Secretary-General's report on the protection of civilians issued in May 2021. In Yemen, for example, half of the country's health facilities are dysfunctional and 18% of its 333 districts have no doctors at all, while water and sanitation systems have collapsed. A large number of medical facilities have been put out of service in Idlib, northwest Syria. In 2020, 24% of the civilians surveyed in northwest Syria reported being unable to receive medical treatment because of an attack on a health-care facility, and 49% said they were afraid to access medical care out of fear of an attack. In the Tigray region of Ethiopia, only 31 of more than 260 health centres were fully functional and only 7 were partially functional by the end of 2020. These figures illustrate the extent to which health systems are severely hampered in situations of armed conflict, including in areas under the control of non-State armed groups. In addition, we often hear reports of the criminalization of impartial medical care provided to populations under the control of groups that are designated as terrorist.  

Low public trust in conflict settings exacerbates challenges to vaccination. Weak governance can heighten exposure to misinformation and disinformation, which have been detected in a number of situations of conflict where non-State armed groups operate or are in control. In Syria, for example, hesitancy has been reported, including among health staff, due to rumors and conspiracy theories on social media and misinformation. In Somalia, Al Shabaab has warned the population against administering the AstraZeneca vaccine, echoing the ban in some European countries and labeling it as deadly and unsafe. In Yemen, the Houthis have reportedly denied the gravity of the pandemic and refused to allow the WHO to supervise vaccine administration, while the public perceives that the vaccine is a deliberate conspiracy threatening people's health.

Yet another challenge to vaccination is, of course, the general scarcity of the vaccine across many parts of the world. One context that illustrates the compounding effects of the challenges listed so far is the Democratic Republic of the Congo. In March 2021 the DRC received 1.7 million doses of the vaccine but had to return 1.3 million of these because they were not able to administer them before they expired. This was in part because it was the AstraZeneca vaccine at a time when it was under investigation in Europe, but also because of general hesitancy and gaps in the ability of the healthcare system to roll it out adequately and quickly enough.

Last year, the UN Security Council adopted resolution 2565, which explicitly recognized that those affected by conflict and insecurity are particularly at risk of being left behind. The resolution called for COVID-19 national vaccination plans to encompass, among others, those living in areas under the control of non-State armed groups. It called for full, safe and unhindered access for humanitarian and medical personnel and assets to facilitate COVID-19 vaccinations. It also recalled the need to address misinformation and disinformation, called for respect for international humanitarian and human rights law, and invited Special Envoys and Representatives of the Secretary-General to use their good offices and mediation with all parties to armed conflict.

In order to vaccinate populations under the control of non-State armed groups, continued engagement with these groups is vital for tackling misinformation and disinformation, obtaining access to populations, and ensuring respect for international humanitarian law and human rights.

This blog post is part of a series on 'The Role of Non-State Armed Groups in Addressing the COVID-19 Pandemic'. It builds on the authors' presentations at the 2021 Sanremo Roundtable on ' Pandemics, armed conflict, and international humanitarian law'. Recordings of the panel presentations can be found here

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