Afghanistan’s Moment of Risk and Opportunity
A Path to Peace for the Country and the Region
In late August, Moaz and Nawraz, a pair of conjoined twins, died in Syria. To be sure, the odds were always stacked against the pair, who were joined at the chest and born in the world’s deadliest war zone. But they were quite healthy, nursing and living without special support. They had been safely transferred to Damascus, and had received offers of medical evacuation from the United States, various European countries, and Saudi Arabia—all expenses paid. Yet the government of President Bashar al-Assad declined the help and stopped all visits from their nursing mother. Five days later, they were announced dead at a little over one month old.
Conjoined twins are small miracles of survival. Identical twins joined in utero are conceived more commonly than we think, but most don’t make it to term. As a result, they constitute roughly one in 200,000 live births. Such twins who then live through their first two weeks have an excellent chance of long-term survival. Classified according to anatomy, most are joined at the chest or abdomen. Some share buttocks or genitals, even heads. Eng and Chang Bunker, the original “Siamese” twins born in Thailand in 1811, were attached slightly above the hip, with a fused liver and a single pair of arms. Many twins are successfully surgically separated, with the highest success rate for twins with separate hearts who are joined at the chest or abdomen, such as Moaz and Nawraz. Many more live conjoined lives, as did Eng and Chang, who moved to North Carolina, married two sisters, and shared professional success, sex lives, and sickness. They died together at the age of 63.
Moaz and Nawraz could have had such a life. They were born on July 23, 2016 in opposition-held eastern Ghouta, a suburban area near Damascus that is home to 400,000 people. Weighing a little over 12 pounds, they were delivered by elective Caesarian section. Mirvat, their mother, knew that she was expecting twins, but she had no idea that they’d be conjoined.
Left to themselves, babies tend to be born at night. It’s evolutionarily protective—there are fewer predators around. Caesarian sections, scheduled during the day for obvious reasons, are riskier for both mother and child than vaginal delivery, but for pregnancies considered high-risk such as twins, let alone conjoined ones, it’s preferable to be born during working hours at a medical facility when more doctors are around. In California, the rate of Caesarian section ranges from 11–69 percent depending on factors such as hospital choice, obstetric tolerance for long labors, maternal preference, and the financial rewards for surgical delivery.
In eastern Ghouta, the rate of Caesarian sections is even higher: 60–70 percent of all deliveries. The near-constant attacks and siege by the Syrian government since November 2012 have created radically different incentives than in California. It is simply too dangerous to spend hours in labor. The government targets civilians, assassinates doctors, and systematically destroys healthcare facilities outside of government-controlled territory—and it typically does so at night. In July, 43 hospitals across Syria were attacked by the Syrian and Russian militaries, the worst month on record since 2011. In August, ten more medical personnel were killed, bringing the total killed by Syrian and Russian forces to over 700 healthcare workers. Even if a woman does decide to risk labor, there are few ambulances to take her to the hospital and little fuel for non-emergent transport. There are no streetlights, moreover, because those would increase visibility to the Syrian and Russian air forces, as would headlights on emergency vehicles. And so, the ride would be in the dark.
In the United States, where it is mandatory for women who are pregnant with twins (or triplets or more) to have a three-dimensional ultrasound, conjoinment is typically diagnosed in the second trimester. This provides ample time for investigation and planning, which is essential because the odds of long-term survival and successful surgery depend on the complexity of the conjoinment and whether the babies share vital organs. The Caesarian section is scheduled according to lung maturity as determined by amniocentesis.
In eastern Ghouta, where just three obstetricians manage over 500 new babies each month, prenatal care has been substantially reduced from pre-conflict levels. For example, maternal screening for anemia, blood group and Rh Factor, and infections such as Hepatitis B and HIV can’t be done, nor triple testing for Down syndrome or other genetic concerns. These days, women are lucky if they can get iron supplements, multivitamins even more so. Still, every woman receives at least one ultrasound during her pregnancy, which provides much more reliable expected delivery dates than guestimation based on a patient’s recall of her last menstrual period and sexual activity. Such information is invaluable for scheduling a Caesarian section; Ghouta is not the place to have an unnecessarily premature baby. The only scan that is available there is two-dimensional—good enough for accurate dates and the confirmation of twins, but insufficient to detect relatively mild conjoinment.
For both Mirvat, 36 years old with three other kids, and the surgeon, Bakr (who uses an alias to protect himself), the Caesarian section was entirely routine. It’s hard to shock a Syrian doctor—Bakr is familiar with the trauma caused by snipers and barrel bombs, the seizures and suffocation caused by chemical weapons, the horrific burns left by incendiary bombs, the mutilation caused by torture. But even he was shaken when Moaz and Nawraz appeared.
Both twins had cleft lips, and being joined at the chest and tummy meant that there was a risk of congenital heart, liver, or other gastro-intestinal defect. On the plus side, neither had any breathing problems or outward suggestions of sinister heart defects, and at over 12 pounds, their combined birthweight was better than average for healthy twins. Their upper chests were apart, suggesting they had the mildest form of conjoined syndrome, in which only the xiphoid cartilage, (from the navel to the lower breast bone) is fused and most major organs are separate, although sometimes the liver is shared. Xiphopagus twins are very well suited for surgical separation, with high expectations of success. From the beginning, both twins breast-fed normally, despite the clefts. They were doing so well, in fact, that they were discharged from the hospital the day after they were born.
Still, on July 24, Bakr asked his colleagues at the Syrian Arab Red Crescent (SARC) in Douma, the biggest town in eastern Ghouta, to contact SARC in Damascus to request evacuation of the twins to Damascus, so they could be transported to a specialized hospital abroad for specialized evaluation, and the hope of separation.
SARC volunteers on the ground typically do their best to arrange such evacuations, but their efforts are compromised at best, and manipulated at worst by the partisan leadership of Abdul-Rahman Attar, who has been described in The Lancet as “one of the country's wealthiest men, with business ties to Assad’s cousin, Rami Makhlouf.” On August 7, after two weeks of repeated calls for help without a response from SARC, Bakr contacted Mohammed Katoub, a former medical colleague in Ghouta, who is now working for the Syrian American Medical Society (SAMS) in Gaziantep, Turkey. SAMS contacted the relevant agencies in Damascus—the World Health Organization (WHO), the International Committee of the Red Cross (ICRC), the United Nations Office for Coordination of Humanitarian Affairs (OCHA), and the U.S. State Department.
On August 10, after another 72 hours without action, SAMS organized a social-media campaign, #EvacuatetheTwins. Within 48 hours, the sudden international visibility had a clear result: SARC finally evacuated the twins to Damascus, along with their mother and aunt. Their father could not risk accompanying his sons for fear of being arrested, tortured, or killed by the regime.
Media photos of the twins at the time of their transfer show both looking very well. They were not even on oxygen. Contrary to the assertion of Elizabeth Hoff, Director of WHO Syria, who told Reuters that the twins had gone to General Pediatric Hospital, they were taken to a private hospital. The hospital was insufficiently resourced to investigate the twins’ condition—for that, they had to visit the pediatric hospital the next day for 3D echocardiography and a CT scan—but it had a different benefit: the hospital allowed the Syrian regime to control exactly who saw the twins.
Between August 12 and 24, several international news agencies, including the BBC, Reuters, and The Wall Street Journal reported on the twins, commenting that international evacuation was delayed as the family waited for passports to be issued. SAMS received hundreds of offers of support; some human traffickers even volunteered to smuggle the twins out to Turkey or Lebanon, free of charge. Within days, a firm offer for medical evacuation from Beirut had come from the United States as well as preliminary offers from Germany, Portugal, and Saudi Arabia. Damascus rejected these in preference of an offer from Gesu Bambino Hospital in Rome, which is not known to specialize in conjoined twins. The government’s reasoning isn’t clear, but it may be relevant that the head of the Italian Red Cross is reportedly friendly with Attar, and that Italy may have been willing to retrieve the twins directly from Damascus rather than from Beirut. But the Ministry of Foreign Affairs delayed giving the required travel authorization for Mirvat and her sons. And then, late on August 23, Moaz and Nawraz were suddenly dead.
In a press release issued on August 24, SARC suggested that the twins’ anomalies had been dire. To most observers, it was clear that the children’s cardiac anomalies were not particularly urgent. According to the SARC press release one twin had a Ventricular Septal Defect (VSD) and the other a Tetralogy of Fallot (ToF). A VSD is a hole between the right and left ventricular chambers; a large VSD can cause heart failure, but it would have left the twin unable to breast-feed and in need of intravenous medication, oxygen, fluid restriction, intubation, and ventilation—none of which was the case. Tetralogy of Fallot is a common congenital heart defect that, if left untreated, causes 50 percent mortality by six years of age, but rarely causes problems in the first few months of life. If the twins’ anomalies were as severe as SARC suggested after their death, it is extremely unlikely that they would have been born at term following an uncomplicated pregnancy and at such a healthy birthweight.
Truth is classically, if tritely, the first casualty of war. Although SARC insists that eastern Ghouta doctors had refused offers to evacuate the twins as early as July 24, there is no digital evidence of any communication from SARC or any international agency to Ghouta until August 9, when WHO spoke to doctors in Mirvat’s town. SARC claimed the liver was abnormal, but the children were feeding normally and growing. Moreover, as the biggest organ visible, a single fused liver would have been detected on the pre-natal ultrasounds. SARC claimed that heart failure was the cause of death, even though this diagnosis is inconsistent with the cardiac abnormalities present. Beginning on the August 19, Mirvat was suddenly blocked from seeing her children, even though the twins were fully breast-fed. She never saw them alive again.
Even after their death, Mirvat was denied the smallest mercy of being able to take her boys home to be buried in their own community. Instead, on August 25, they were interred in Najha, a massive cemetery in southern Damascus where hundreds of Assad’s torture and execution victims memorialized in the “Caesar photographs” were buried. Mirvat was only allowed to return to eastern Ghouta on August 29.
In short, the circumstances of the twins’ death and the way their mother was treated are disturbing. It is unclear why the Syrian authorities took so long to issue passports for the twins; why was the mother denied access to them for days; why she was not allowed to bury her sons in eastern Ghouta; and, most worrying of all, how they really died.
It also seems unnecessarily cruel. Unless there was some concealed reason, for instance if surgeons at the direction of the Assad government had attempted surgical separation in Damascus. After all, it would have been a massive public relations coup if the surgery were successful. A botched effort, however, would explain their death and the hasty burial in a massive war cemetery south of Damascus. It is notable that although it took an ostensible nine days to get passports, it took less than one to get the death certificate.
Whatever the precise reason for the twins’ death, the broader cause may be found in the Syrian government’s conduct of the war, during which it has deliberately targeted civilians and especially their medical care in an effort to depopulate areas controlled by the armed opposition. Moaz and Nawraz are only two of hundreds of thousands of children starved, denied access to healthcare, and endangered on a daily basis. If the children had left the hospital alive, they may well have perished anyway if they returned to eastern Ghouta, whether due to the government’s siege, its barrel bombs, landmines, snipers, and chemical weapons, or with Russian help, its increasingly targeted aerial attacks on civilians and civilian institutions.
The Syrian government gets away with its war-crime strategy in large part because of the complacency or even complicity of external actors. Russia has provided the Assad regime with the military life support it needs to sustain its murderous methods. Rather than publicly pressure the Kremlin to use that leverage to end the targeting of civilians, the U.S. government has been treating Russia as a credible partner in peace efforts.
Meanwhile, several UN agencies—OCHA, UNICEF, UNHCR, and WHO—have been funding Assad’s killing machine, as a recent Guardian exposé showed. UNICEF, founded to protect children, has said little about Assad’s targeting of children as it channels funds through Syrian businessmen such as Rami Maklouf, one of Assad’s closest allies. UNHCR partners with Asma Assad, who is Assad’s wife and is also on the U.S. and EU sanctions list, providing her charity, Syria Trust, with nearly $8 million since 2012. WHO supports the National Blood Bank to the tune of over $5 million. Trouble is, Blood Bank is run not by the Ministry of Health, but by the Ministry of Defense. Blood Bank only supplies hospitals in government territory with transfusion equipment, blood-donation bags, and screening kits (military hospitals get their needs met first of all). Even worse, the Ministry of Defense is responsible for targeting civilians, bombing hospitals, ongoing chemical attacks, and use of incendiary weapons (such as napalm) on civilians. Al Mezzah 601 Military Hospital, where thousands of “Caesar” victims were incarcerated and killed, is run by the Ministry of Defense.
It is hard enough to accept that the twins apparently never had a chance once they were placed in the hands of the Assad regime. It is harder still to accept that the supposed guardians of international humanitarian assistance did so little to intervene or to ask questions—in this case or in countless others when the Syrian government has feigned concern about the welfare of civilians in opposition-held areas even as it did everything it could to undermine it. As long as international organizations maintain a presence in Damascus (the United Nations is based out of the Four Seasons there), they provide legitimacy to the Syrian government. Without them, the Assad regime would more likely be seen as a collection of military thugs operating under the Assad family dictatorship.
The Syrian crisis is horrific, but it can still be mitigated. The first step will be admitting the failure of the strategy of disbursing billions of dollars to Damascus, creating hundreds of jobs, and providing financial and political support to the Syrian government as the price for having access to some civilians in Syria. Moaz and Nawraz, two kids out of roughly seven million whose futures have been compromised, threatened, or terminated by the Syrian government, are already in danger of being forgotten. But their brief lives, a lifelong source of grief for their parents, clarify the depravity of the government and the danger of the compromises that international humanitarian organizations have made. It would be desirable to have a modicum of medical competence at WHO Syria, which not only failed to recognize the absurdity of the stated cause of death, but blamed the parents for the twins’ deaths, calling them responsible for the delay in international transport and callously accusing the father of demanding evacuation directly to Saudi Arabia. The father wasn’t even in Damascus, and neither he nor Mirvat were in a position to demand anything. The parents placed their whole trust in SARC and the UN agencies to do the best for their sons, and international governments pledging assistance expected basic medical competence from WHO.
There are other ways to spend the billions of aid money being disbursed via Damascus. The United Nations should deepen its support for Syrian NGOs working in opposition-held parts of Syria. Eight million needy Syrians live there. They are reachable through humanitarian efforts operating over the border in Turkey, Lebanon, and Jordan. Unlike the Assad regime, these NGOs are not killing anyone and are distributing aid impartially according to need.
There are minimum standards of humanity. We should uphold them, rather than accept Assad’s lies about flouting them or endorse the United Nation’s complicity in their reduction. Children need our protection; they also need to know that, even as the United Nations and donor governments fail them, we will try to do better the next time. For now, there is still more life than death in Syria. It is time to protect children who are still alive, and provide hope of protection for the young Syrians yet to come.