Photo by AAREF WATAD/AFP via Getty Images

In early March, the already-tense atmosphere in Damascus’s central hospital grew darker and fear more pervasive. Rumors were circulating that hospitals were facing huge numbers of COVID-19 cases and patients infected by the virus were being liquidated. In reality, a handful of patients presenting symptoms reached the hospital but were not tested, even though the staff collected samples from them and the World Health Organization (WHO) had already delivered the polymerase chain reaction (PCR) machines needed to do the testing. Hassan,* an experienced doctor working at the hospital, became even more acutely aware of the constant presence of secret police (mukhabarat) officers. Usually, they would guard patients who were political detainees, preventing them from communicating with the staff. Now they had a new mission: making sure no information about possible COVID-19 cases got out. 

Syria has since stopped denying the arrival of the virus in the country. Officially, it has just 42 COVID-19 cases, all but one of them in regime-held areas, as testing capacity is almost non-existent elsewhere. The actual number of cases is certainly higher, but there appear to be few severe cases at the moment. Yet, interviews with doctors and NGO workers conducted over the phone and via messaging apps across all areas of control in Syria paint a grim picture of a health care sector utterly unprepared for a pandemic.

Syria’s debilitated health sector

Syrians across the country will not be spared the effects of Syria’s debilitated health infrastructure, but some will face even worse odds than others. Syria’s health care system has been ravaged by years of conflict, with 70 percent of health care workers, especially the most qualified, fleeing the country since the outbreak of the uprising that turned into a civil war. The Syrian regime and Russian air force destroyed most of the country’s public hospitals. Even before the war, public hospitals provided a low standard of care, but this has only deteriorated since, across all areas of the country. Medical supplies are low and at times nonexistent, patients often die of wounds and diseases that are not severe, and medical staff are overworked and often under-qualified. The number of ambulances is limited, inhibiting access to care, particularly in towns and villages distant from major urban hubs.

While all authorities in control of Syria’s divided map claim to be combatting the virus by imposing their own lockdowns, insulating Syria from the world and maintaining isolation of the different areas of control is impossible due to the porousness of its external borders and internal dividing lines. Smuggling continues between all areas of Syria, as well as across the border with Turkey (including of returning refugees, some of them young men who lost their jobs due to COVID-related work stoppages) and Lebanon, while pro-Iranian militias continue entering from Iraq and Lebanon as well. While 41 COVID-19 cases have been recorded in areas under regime control and one case in areas under the control of the Syrian Democratic Forces (SDF) in the northeast, doctors, epidemiologists, and NGO workers believe that it is only a matter of time until the pandemic spreads to other areas as well, if it has not done so already. 

Experts and doctors working across Syria fear that the pandemic will spread quickly due to overcrowding and an inability to self-isolate, under-testing for COVID-19, a lack of capacity for contract tracing to isolate identified cases, and poor access to health facilities. Even if Syrians take the pandemic seriously (and many currently do not), a large share of the population must work daily for a living to survive, making long-term work stoppages untenable. Millions of people in Syria live in densely populated areas, including prisons, internally displaced person (IDP) camps, and slums. If the coronavirus is introduced into such settings, it will likely result in mass infections. 

The number of doctors left in Syria who are qualified to deal with COVID-19 patients is quite limited. Media reports and estimates often measure the capacity of the Syrian health sector by counting the numbers of ventilators and intensive care unit (ICU) beds, but the real bottleneck appears to be the lack of qualified personnel to run the ventilators. “A patient on a ventilator needs a highly trained doctor. Their body stopped working; their life completely depends on the doctor,” explained Dr. Omar al-Hiraki, who works at the Bab al-Hawa hospital in Idlib. The training required to oversee patients on ventilators is complex. According to Şevger Kevok, an emergency medicine doctor from the UK volunteering in northeast Syria, “the numbers of staff cannot be scaled up quickly. Teaching this is not something you can learn in crash-course training. Triaging and dealing with war injuries is possible to learn in a few days, and we did this during the Turkish invasion in October [2019], but not handling patients on ventilators.”

“We don’t have the capacities to deal with critical cases. They will die,” said Dr. al-Hiraki in a pained voice. “Most of those who end up on ventilators in Idlib, even if they are then transferred to Turkey after a couple of days, end up dying.” The likelihood that most patients put on ventilators will die won’t significantly increase the availability of this vital resource, explained Alex, a coordinator overseeing the response to northeast Syria at an international NGO, who asked that their real name be withheld to speak frankly. “The turnover of beds might be faster because of the lack of ICU capacity, as those patients might unfortunately die. But even in the non-critical patients who can be saved, they may need to be hospitalized for 2-3 weeks, so those cases will quickly clog up the system.” 

Grim projections

If the pandemic is not stopped in its tracks, many of the few hundred doctors and nurses able to treat severe COVID-19 cases will likely become infected themselves, particularly given the scarcity of protective equipment and the inadequate infection, prevention, and control (IPC) procedures. NGO workers and doctors expect hospitals currently reserved for treating non-COVID patients to become infected as well and have to shut down for repeated cycles of disinfection or turn into COVID-19 wards. “If the repurposed hospitals cannot treat severe cases, this conversion of the hospital won’t be particularly beneficial,” warned Hakim Khaldi, the Syria head of mission at Médecins Sans Frontières (MSF). It will also mean that individuals suffering from health conditions that can be treated even with limited capacities, will not be able to access services.

Despite the ongoing valiant efforts of international and local NGOs, as well as UN agencies, to increase the ability of local health systems to deal with the crisis, the impact will likely be limited. “Even with foreign assistance, it is extremely unlikely that Syria — either the regime or the opposition-held areas — will be able to scale up bed capacity. Based on what we know at present, the projected needs for intensive care capacity would far outstrip what is currently available,” wrote Dr. Francesco Checchi, a professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine (LSHTM), in an emailed response to questions.

While experts are careful about providing projections on the outbreak of the pandemic in Syria, given the many unknown variables and lack of similar cases thus far, the combination of density and poor health infrastructure is worrying doctors and NGO workers. A model developed for a large and highly dense refugee camp in Bangladesh by the Johns Hopkins Bloomberg School of Public Health foresees that due to the inability to isolate the population, the majority of those in the camp will contract the virus. When asked to assess how an outbreak of the virus will manifest in Idlib, Dr. Shaun Truelove, the lead author of the model, commented in an emailed response that “a very high proportion of the population is likely to be infected.” Based on data provided to him by the authors about Idlib’s health sector capacity, he added, “we have not done any analysis for this population, but based on these numbers I would expect these hospitalization, ICU, and ventilation capacities to be rapidly overwhelmed, with many time fold the number needed as compared with capacity.”

For its part, the WHO appears to foresee a minor outbreak in Syria. In meetings in Damascus with the Ministry of Health as well as with NGOs taking part in the health cluster in Gaziantep, which is in charge of cross-border aid into northwestern Syria, WHO representatives presented slides based on the virus’s officially declared attack rate in Wuhan, China: 115 infections per 100,000 people, and only 5 percent of them critical. “We told WHO it makes no sense to apply the Wuhan model in Idlib, a place with no government, no capacities, [where] mass gatherings continue. Just a few days ago there was a football match in Qah [northern Idlib]. I asked them, ‘Why are you using the Wuhan attack rate? In Michigan the attack rate is 244 for 100,000. Why are you applying Wuhan and not Michigan?,’” said Dr. Abdul Rahman al-Omar, a senior health adviser with the Syrian American Medical Society (SAMS) who attended the meeting. In Wuhan, extreme social distancing measures were put in place, including welding the doors of apartments shut to prevent residents from leaving. China’s health infrastructure was also in a much better position — not destroyed by war, like Syria’s. In addition, the official attack rate reported by the Chinese regime appears highly questionable, and Beijing admits to only counting symptomatic cases

Oddly, the WHO appears to assess that Syria will do better than Wuhan. “WHO told us that they believe the appropriate model for Idlib is 50 percent of the attack rate in Wuhan,” said Dr. al-Omar. Thus, the WHO estimates that 2,413 people will get infected among the 4 million residents of northwest Syria and just 121 will need ICU care. Damascus settled on the 25 percent attack rate scenario, and is thus preparing to have about 2,445 cases overall out of the 8.5 million Syrians living under its control, and about 122 patients reaching critical care. The Idlib and Damascus response plans to the crisis are based on these assumptions. 

As countries around the world shut down their borders and economies, three of the four governing structures ruling over Syria, in all areas other than Idlib, have instituted work stoppages, borrowing from countries that did so earlier, such as China and developed countries in Asia and the West. Syria is not the only impoverished country to adopt such solutions: across the global south, governments have shut down their economies. In the West and East Asia, these shutdowns are used to scale up hospital capacity and put in place mass testing and contract-tracing systems to allow these countries to better deal with the pandemic once the restrictions are partially relaxed, until a vaccine is found. In Syria, attempts to build up capacity in no way will be able to meet the scale of the needs due to the lack of resources, both financial and human. Meanwhile, the impact of the work stoppages on the economy is already devastating, as many Syrians rely on day labor to put food on the table.

An alternative to copying the model used in developed countries, advocated by epidemiologists at the LSHTM, is shielding the most vulnerable in the population. This solution would entail keeping in relative isolation those most vulnerable to the outbreak, such as the elderly and immunocompromised, while the rest of the population becomes infected, recovers, and develops herd immunity. The experts at LSHTM believe this is the inevitable outcome in low-income and war-torn settings. This solution, however, requires the buy-in of governing authorities, communities, and NGOs, while across the world, countries and societies rushed to take action only after the epidemic started spreading. 

Photo by LOUAI BESHARA/AFP via Getty Images
A member of the sanitary section of Al-Assad University Hospital in Damascus runs blood tests at a special department designated for testing people with symptoms of COVID-19, on April 15, 2020. 
Photo by LOUAI BESHARA/AFP via Getty Images

 

Regime-held areas: Securitized and incompetent response

Throughout the war, long-time problems that have plagued Syria’s health system were exacerbated, namely, corruption, profiteering, appointments based on loyalty, and geographic disparities in the quality of care. Thus, the health care system in regime-held Syria reflects larger trends in service provision in the country. The unchecked corruption and impunity afforded to state officials manifests in a widespread phenomenon of theft of medical supplies from state hospitals by staff and demands that patients pay for medical examinations. Even before the war, areas outside of the cities of Damascus, Aleppo, Tartous, and Latakia had limited access to quality health care. 

During the war, provision of all services, including health care, became even more closely linked to perceived loyalty. The Syrian regime and Russia pummeled areas that fell out of regime control, such as southern Syria, eastern Ghouta, and Homs, and specifically targeted medical facilities and personnel. Because the regime targets medical workers for arrest, during the surrender deals imposed by the regime — framed as “reconciliation” agreements — a large share of the medical staff chose to be displaced to the rebel-held north rather than remain under regime control. Since the regime’s reconquest of these areas, health services have largely not been restored and hospitals were not rebuilt. “During the days of the opposition services were better than now,” said Mohammad, an employee of the Ministry of Electricity living in Harasta, which was reconquered by the Syrian Army in 2018 after a five-year siege. “Despite the lack of medical equipment and drugs, at least the doctors and nurses tried to do their best to provide services to all. Now care in regime hospitals is based on connections and favoritism.”

The Assad regime’s management of the COVID-19 crisis shows that it continues to prioritize its own extremely parochial, security-centric interests in ways that blatantly undermine public health. Multiple decisions made by the regime have already hindered the ability of medical professionals to tackle the crisis and of citizens to protect themselves from the spread of the virus. These decisions include not shutting down flights from Iran, an epicenter of the pandemic; continuing to allow pro-Iranian militiamen and Iranian advisers to enter Syria from Iraq and Lebanon and interact with Syrian soldiers, militiamen, and scientists; granting the secret police a prominent role in managing the crisis, deterring civilians and particularly regime opponents from seeking medical assistance or informing on suspected COVID-19 cases; refusing to allow the WHO to establish a lab with a PCR machine that can conduct testing for the SARS-CoV2 virus in northeast Syria, significantly hindering the ability to quickly trace cases and isolate those who have come into contact with them; not disclosing crucial information about identified COVID-19 cases to allow communities to protect themselves; and creating public messaging that will likely deter individuals from reporting on suspected cases or asking to be tested themselves. 

Other steps taken by the regime appear to stem from incompetence. The Ministry of Health did not carry out tests for a whole month after receiving PCR machines from the WHO in mid-February; individuals whose relatives are suspected of becoming infected are not notified about the test results for days, during which they continue to move around and potentially spread the virus; the government imposed lockdown measures that increase congestion in the streets; the Ministry of Health is still not testing individuals who have come in contact with confirmed COVID-19 cases; the government is not providing clear information about how individuals who believe they are suffering from the virus should get tested; and the Ministry of Health has not supplied medical personnel with personal protective equipment (PPE), informed them about COVID-19 symptoms, or trained them on IPC measures.

Damascus has taken a number of steps to reduce the spread of the virus, including closing schools and universities, ending communal prayers in mosques, ordering the closing of shops, reducing the work hours of state employees, ending movement between governorates, and instituting a curfew from 6pm until 6am. As a result of the latter, however, food markets and distribution centers for subsidized food are overcrowded during their hours of operation. 

The ever-present secret police

Similar to the handling of the crisis in China and Iran, rather than trying to get ahead of the situation, Damascus has sought to keep it invisible. The regime’s knee-jerk reaction to the outbreak was to try to control what information got out. The various branches of the mukhabarat, the core of the regime’s ruling apparatus, were deployed to control the information environment. Outside of hospitals, the mukhabarat arrested individuals who spread rumors on social media about possible COVID-19 cases and even when they communicated accurate information. When one resident of the Damascus countryside informed his colleagues through a WhatsApp group that another colleague was sick, he was arrested, even though such information could encourage individuals to get tested and or self-isolate to prevent the spread of the virus. 

Doctors working in community clinics described receiving visits from the mukhabarat after daring to send patients suspected of COVID-19 for further tests in Damascus. Daoud, a doctor who runs a private clinic in an area bordering Lebanon, recounted receiving a patient who entered Syria through an irregular border crossing from Lebanon. The patient presented signs of COVID-19 and Daoud directed him to go for testing in Damascus. “The mukhabarat came to visit me and told me to inform them when I receive suspected COVID-19 cases. I was ordered not to direct cases on my own, or they’ll shut down my clinic. They threatened me to disclose the name and details of the patient.”

Inside hospitals, the secret police have further tightened their grip over the medical staff. Following the start of the Syrian uprising in 2011, mukhabarat officers were deployed to all major hospitals and are assigned their own office. Doctors described a climate of fear, as fellow doctors, nurses, and even cleaning staff inform on one another to the secret police. “Our role as doctors is merely to execute the orders of the mukhabarat,” said Fatima, a young doctor working at a central state-run hospital in Damascus. “They intervene in the decisions of the director of the hospital and the head physician. They intervene even on issues of who gets x-rays and other tests.”

The outbreak of COVID-19 has further bolstered the influence of the mukhabarat inside hospitals. “They’re behaving in the hospital as if we’re a branch of the secret police. Weird things are happening at the hospital,” said Hassan, the doctor working at a major hospital in Damascus. Initially, he reports, when the regime continued to insist that Syria was free of COVID-19 cases, the mukhabarat warned the doctors to avoid alerting anyone about possible cases and register those who appeared to have died of COVID-19 as dying from pneumonia. After cases started being reported, “they couldn’t say anymore that there are no cases but the secrecy remains. There is a special team taking care of the COVID patients and suspected COVID patients. The other staff are not allowed to learn any information about them. The names of the patients are unknown; we can’t enter their wards.”

The securitized response of the Assad regime will likely have deadly consequences. The initial instinct of the regime to avoid reporting cases meant that individuals went undiagnosed and their relatives were not tested. In addition, concerns about the hospitals — from the low quality of care and the lack of cleanliness to the role of the secret police in tracking cases and enforcing home isolations, as well as unproven rumors that the secret police were killing patients — are deterring Syrians from trying to obtain care even if they feel sick. Multiple individuals interviewed in regime-held areas reported that if they suspect that they’ve been infected with COVID-19, they will avoid notifying authorities or seeking medical care unless they genuinely believe they are about to die. The regime’s practice of arresting men wanted for military service in hospitals may also deter young men from seeking treatment. Thousands of suspected regime opponents who have been able to hide out in areas the regime does not tightly control, particularly in southern Syria and rural areas, will also not dare to cross regime checkpoints in search of better medical care, only available in major cities.

Secrecy and paranoia

The regime has also imposed quarantines on specific towns and buildings. Damascus closed off movement from the towns of Mneen, after a resident died of COVID-19, and the Damascus suburb of Sayyida Zainab, the staging ground for multiple Shi’a militias originating in Lebanon, Iraq, and Afghanistan, as well as Iranian advisers. The health authorities did not provide residents of these towns with information about the number of cases discovered there. In Mneen, it was the family of the resident who passed away that publicly confirmed she had died of COVID-19. They were unable to alert the community until a week after her hospitalization because they were not informed that she had tested positive for COVID then. In Sayyida Zainab, the regime did not provide any information about the existence of cases, claiming the area was quarantined due to its population density, while other densely populated neighborhoods in Syria have not been placed under lockdown. In addition, the mukhabarat sealed off buildings in several towns, including Douma, Qudsiya, and Sayyida Zainab, without giving any explanations to the community. Dr. Daoud reports that the mukhabarat placed the family of a suspected patient in quarantine in their home for 20 days “but they did not test whether his relatives have the virus.” 

The regime’s paranoia and efforts to prevent reporting on the spread of the virus may also stem from the perceived and actual role of foreign Shi’a militiamen and Iranian advisers in doing so. Rumors spread inside Syrian Army units working with Iranian advisers or near Iraqi and Lebanese militiamen in Palmyra and the Idlib frontlines that soldiers contracted the virus from the foreign Shi’a fighters. According to a young Damascene man who serves in the Military Research Center in Jamraya as a chemist, two of his colleagues were quarantined in Qudsiya and Sayyida Zainab with their families, after contracting the virus from an Iranian adviser working with them in a facility in Homs Governorate that manufactures long-range missiles. He himself is worried. Several of the center’s engineers and experts recently returned from training in Iran. Most of them are from the coast and were placed in quarantine there after returning, but only after coming in contact with some of the center’s other employees.

All doctors interviewed in regime-held areas doubted the ability of the health sector to cope with the pandemic due to the lack of professional staff capable of dealing with complicated cases, the sector’s poor and corrupt management, and the widespread lack of equipment. They are also worried about being exposed to the virus due to the shortage of protective gear. “We have nothing to protect ourselves,” reported Hassan, working in Damascus. He said that “the medical staff, hesitantly, asked [the administration] for gloves, protective gear, and the response was that ‘we are in a siege, the U.S. and Israel are to blame. These are the means we have at our disposal.’” Corruption is at play here too: “A nurse distributes surgical masks, not N95 [respirator masks], and those with good ties with her get masks and others don’t. I had to buy my own mask and alcohol for exorbitant prices” due to price gouging. 

The regime’s dungeons

The most vulnerable population in regime-held areas to COVID-19 are prisoners, especially the tens of thousands of political prisoners who are held in particularly harsh conditions amid extreme overcrowding. Detainees are starved, tortured to death, and denied medical care. Ali, who was detained for seven and a half years for attempting to defect from military service, was held in the notorious Sednaya prison for three years and released in late 2019. “Diseases are incredibly common among the detainees, and particularly asthma, tuberculosis, scabies, and hepatitis.” Detainees largely avoid going to the doctor because “there are guards at the doctor who beat you up so that the detainee doesn’t ask again to be taken to the doctor.”

Following the spread of the virus, guards in prisons holding political detainees began donning masks and gloves. “They wear the same mask all day and it becomes filthy,” reported Hammoud, who was released from detention during the first week of April. Hammoud is a former rebel who decided to remain in his town near Damascus after the regime reconquered it and underwent the bureaucratic process of “settling his status” with the regime. In a pattern repeated across areas that went through the so-called reconciliation process, he was arrested in 2019 for belonging to a terrorist group. 

In March, Hammoud and his cellmates in the Damascus prison were taken out of their cells. “We were gathered in large courtyards, ordered to strip naked, and sprayed with Povidone diluted with water.” Povidone-iodine is used to sterilize wounds and can in no way disinfect or cure a person of coronavirus. While the interrogators start donning gloves and masks, they did not stop the torture, further crippling the ability of the detainees to survive the pandemic and detention. “They also sterilized the rooms, but there is no medicine available other than aspirin. Many diseases spread in the small detention cells, where over 200 people are held together,” he reported. Sick detainees were taken out for medical treatment, but never received any medicine and were returned to the cell to infect others. Detainees often died. Even without the pandemic, “in the normal state of detainees, with our scrawny bodies, the beatings, the non-stop torture, we can’t resist illnesses, especially since we are not fed enough — usually one small piece of bread per day.”

Sanctions

Damascus is trying to use the pandemic to gain relief from the extensive sanctions regime imposed on it, primarily by the U.S. and the EU. Despite the creation of humanitarian exemptions and general licenses for UN agencies and NGOs, Western sanctions are indirectly affecting the humanitarian sector. NGOs and the WHO are required to go through prolonged licensing processes for goods such as CT scanners, laboratory testing machines, and accessories to anesthesia machines, and struggle to bring cash into the country to pay employees. The Syrian regime has not asked for general licenses from the EU or the U.S. to import goods under the humanitarian exemptions. Instead, it is relying on Iran, China, and Russia for the import of often sub-par medical equipment and medicine. Manufacturers, banks, insurance, and shipping companies prefer to end their transactions even with humanitarian organizations linked to Syria, let alone private entities or the Syrian government, for fear of heavy penalties. The U.S., which applies the most extensive sanctions regime on Syria, should reassure companies and banks along the medical equipment supply chain that they will not be sanctioned. 

The regime’s own behavior — the gross corruption, incompetence, and unequal distribution of services based on loyalty — significantly limit the impact of sanctions relief. Past experience shows that efforts to prevent the regime from diverting humanitarian assistance have consistently failed, leading to UN aid going toward supporting pro-regime militias. Countries applying sanctions should consider what concrete, measurable improvements can be gained from the regime in exchange for sanctions relief, such as the release of detainees (possibly starting with medical personnel) or a halt to arrest campaigns and the bombing of hospitals. In exchange, the EU and U.S. could offer to create a humanitarian payment channel (similar to the one established for Iran), unfreeze assets, and take additional steps that would mitigate the impact of the pandemic on Syrians. 

Photo by DELIL SOULEIMAN/AFP via Getty Images
Members of Kurdish security and the Kurdish Red Crescent in protective gear escort a passenger upon arrival from Damascus, to be checked for COVID-19 symptoms outside Syria's
Qamishli airport, on April 7, 2020. Photo by DELIL SOULEIMAN/AFP via Getty Images

 

Northeast Syria: Dependent on a hostile regime

The Autonomous Administration of the SDF governs over about a third of Syria’s territory in the northeast, home to a little over 3 million residents. The local administration took a number of steps in early March to counter the spread of the virus, canceling Friday prayers and banning most mass gatherings, closing crossings into areas under the control of the regime and Turkey’s Syrian factions, ordering citizens to stay at home, and shutting most shops. 

The health sector in northeast Syria has even less capacity to deal with the outbreak than those in regime-held areas and the northwest. “The COVID response is inadequate, despite the best effort of the local authorities,” said Alex, the coordinator for an international NGO working on northeast Syria. “There are currently about 50 beds available for COVID patients in the northeast and they need thousands!” Alex exclaimed. “There are not enough drugs and beds, [and] limited staff to support those beds.” NGOs and local authorities are working to increase the number of beds in the area and recently, the Kurdish Red Crescent (KRC) and the Italian NGO Un Ponte Pei established a hospital-based isolation center with 120 beds, but those can only treat mild to medium cases, reported Dilgesh Issa, a medical coordinator with the KRC. According to Dr. Kevok, the ICU beds in the new facilities “will not all have ventilators or monitors, so it’s impossible to really call it an ICU,” he said. 

While all areas of Syria are affected by movement restrictions due to COVID, the northeast has been hit particularly hard. Following the COVID-19 outbreak, Iraq’s Kurdistan Regional Government shut down the Fesh Khabor/Semalka crossing, but is making an exception for aid and humanitarian employees. However, restrictions on movement within the Kurdistan Region of Iraq (KRI) continue to hinder the ability of NGOs to rush supplies to northeast Syria. The closure of internal crossings within Syria means that NGOs in the northeast and the local authorities struggle to secure basic supplies. “We ordered PPE (masks, aprons), HEPA filters, oxygen masks from several countries in the Middle East,” described Dr. Kevok. “After they arrived in Damascus, they were seized by the Assad regime.” Alex, the international NGO coordinator, explained, “Suppliers in the region tell us that Damascus cut supply lines for PPE and that raw materials aren’t going in from government-held areas. Manufacturers in northeast Syria tell us they can manufacture PPE, but due to smuggling, the costs are prohibitive. For example, a gown that is supposed to be worn for 20 minutes and tossed away will cost $7. Prices are rising up to ten times more due to inability to move products inside the country itself.”

Damascus is using its dominance over aid flows to the northeast to sabotage the region’s ability to respond, with the apparent complicity of the WHO. In January, due to a Russian veto, cross-border UN assistance, carried out through the Yaroubia crossing into Iraq, was ended. This means that all assistance from NGOs registered in Damascus and UN agencies now must be approved by the Assad regime. Following the veto decision, aid for the health sector in northeast Syria was significantly reduced, jeopardizing the ability of the northeast to respond to the pandemic.

Aid provided by the WHO through Damascus to the northeast, including ventilators and ICU beds, arrived in mid-April after delays. In line with the WHO’s past conduct in Syria, the regime was allowed to condition the provision of aid financed by WHO donors on directing aid to those deemed loyal. According to a UN document, 89 percent of the goods in the shipment will be used only within the Qamishli National Hospital, located in an area under regime control on the outskirts of the city. This means that individuals wanted by the Assad regime for military service (most of the region’s men) or political dissent are unlikely to dare to cross regime checkpoints, located on the road to the hospital, in search of medical care. 

The funneling of almost all WHO supplies to a single hospital runs contrary to the efforts of health NGOs and local authorities to bolster preparedness and capacity across all of northeast Syria. Only 26 of the 279 public health centers in northeast Syria are fully functioning, while roads are dilapidated and take a long time to traverse: A journey to Qamishli from southern Deir Ez Zor takes about ten hours, for example.

Testing for COVID-19

The regime is not just hoarding supplies or limiting access to northeast Syria; it is also hampering what capacities are in place and spreading false information. The WHO provided the Syrian Ministry of Health with five PCR machines, and Damascus decided not to send even a single one to the northeast. Accordingly, doctors there were compelled to use one of two routes to send samples to Damascus for testing. The first entails calling in a Rapid Response Team (RRT) supported by the WHO. Alex describes the difficulties encountered so far: “If a health facility calls the RRT for highly suspect cases, they say they can’t get through the checkpoints, they arrive late, or they simply say ‘we’re not coming.’ If they do arrive, they often say ‘these people don’t meet the case definition’ and refuse to swab them, even when they clearly display the symptoms.” According to Dr. Ciwan Mistefa, the co-chair of the Autonomous Administration’s Health Directorate and a human rights researcher working on Syria, the regime’s Health Directorate in Hassakeh ordered the RRT not to collect samples from hospitals that cooperate with NGOs that were not registered and approved by Damascus, such as MSF and the KRC. As a result, in some cases, patients were forced to be transferred to regime-run hospitals for the RRT to be willing to collect samples from them, endangering the health of both the patient and ambulance crews. This conduct is consistent with the WHO’s general refusal to provide assistance and coordinate with NGOs not registered in Damascus, which are responsible for meeting much of the area’s medical needs, said Dilgesh Issa of the KRC.

An alternative route involves shipping the samples to Damascus through the Qamishli airport, which has been used for sending samples for polio and influenza diagnostic tests in the past. “The RRT refused to come to the quarantine hospital in Hassakeh, saying there are too many checkpoints and not enough staff. After the failure to get them to come, we sent the two samples to Damascus on March 31 through the regular route recommended by the WHO, but Damascus says they did not get to them,” said Dr. Kevok. Similarly, samples collected by the RRT in northeast Syria, which the WHO claims tested negative, were apparently never tested, according to a well-placed health sector source who requested anonymity. This means that the Syrian Ministry of Health lab, supported by the WHO, is potentially misreporting cases as negative, when those individuals in fact are infected with COVID-19 and pose a danger to the community around them. 

As a result of the apparent policy of deprioritizing testing in northeast Syria, only 19 samples from the region were sent for testing in Damascus. “There are several samples for which no result was provided. We don’t know if they turned out negative, positive, or even if they were tested,” said Dr. Mistefa of the Autonomous Administration. He added, “There are dozens of suspected cases in northeast Syria. 19 tests for the entire region is a low number, indicating the limited cooperation by the WHO and limited support” provided to the northeast. 

The failure of the COVID-19 testing system in northeast Syria, overseen by a hostile regime and an obedient WHO, became glaringly apparent on April 18, when the Autonomous Administration announced that the WHO had just notified them that a patient whose sample was collected on March 29 and died on April 2 had tested positive for the virus. The WHO informed the Syrian Ministry of Health about the test results on April 2, but the regime refuses to coordinate with the Autonomous Administration and did not pass on this vital information. A spokesperson for the WHO claimed that contract-tracing was carried out after the test came back positive, but humanitarian workers in the region doubt this claim given the RRT’s hands-off approach and limited testing in the area. This conduct is reminiscent of the regime's decision to ban the WHO from providing polio vaccinations in rebel-held Deir Ez Zor in the early years of the war and subsequent efforts by the WHO to cover up the inevitable outbreak of polio there in 2013.

On April 11, long after other areas in Syria, the Autonomous Administration was finally able to obtain two PCR machines from the KRI. Three more machines have arrived since and two are en route, according to Dr. Kevok, all of them transiting through the KRI. On April 20, after undergoing training, local technicians began to carry out COVID-19 tests in Qamishli. The WHO did not deliver any COVID-19 test kits to the region, leaving northeast Syria dependent on continued access to the KRI to acquire the needed supplies. 

Ongoing conflict with Turkey

The October 2019 invasion of northeast Syria by Turkey and the Syrian factions it supports further hinder the ability of the local health sector to respond to the crisis. The fighting displaced tens of thousands of Kurds from the area between Ras al-Ayn and Tel Abyad, changing the demographic makeup. Thousands of these internally displaced families now live in camps across northeast Syria, including the Washokani camp. The ongoing Turkish control of this pocket gave it leverage to routinely cut off Hassakeh Governorate’s water supply, which originates in the Allouk pumping station near Ras al-Ayn. About 460,000 residents of Hassakeh rely on water from the station, including over 100,000 IDPs living in camps such as Washokani, al-Hawl (housing families that fled ISIS as well as those related to members of the group), and the Areesha camp. The on-and-off cutoffs reduced the water supply for the population to about eight liters per day for every person, which is far below the amount needed amid a pandemic that can be warded off by frequent hand-washing. 

Photo by Izzeddin Idilbi/Anadolu Agency via Getty Images
Members of the Syrian civil defense group, White Helmets, carry out disinfection works around the city center as part of precautions against COVID-19, on March 22, 2020 in Idlib, Syria. 
Photo by Izzeddin Idilbi/Anadolu Agency via Getty Images

 

Idlib: Disjointed and under-funded health sector weakened by targeted attacks 

The last stronghold of the Syrian opposition, Idlib and nearby western Aleppo house about three million civilians, most of them displaced from their homes. Over one million of the area’s residents live in overcrowded camps along the border with Turkey, at times two and even three families in one tent. The Russian and Syrian air forces have systematically targeted hospitals, medical clinics, first-responders, and ambulances in the region, leaving Idlib with an incredibly overstretched and fragile health care infrastructure. The regime and its allies have killed over 840 medical personnel to date, many of them through air strikes on critical health infrastructure. 

The “Salvation Government,” linked to the dominant Islamist-jihadist group Hayat Tahrir al-Sham (HTS), which rules over Idlib, took a number of steps to reduce the spread of the virus, including shutting down schools and eventually even Friday prayers, to the displeasure of more hardline elements and many locals. In reality, communal prayers continue in many of the area’s mosques run by prominent families and those under the influence of groups more extreme than HTS. Social distancing is not enforced, and doing so would be incredibly challenging given the high population density and the reliance of many on day labor to survive. Owing to successful pushback from donors and doctors, the Salvation Government has largely avoided interfering in Idlib’s health sector since 2019.

Idlib’s response to the COVID-19 crisis is hampered by a legacy of poor coordination between the various NGOs working in the field. The actors leading the response to COVID-19 in Idlib are international and local NGOs and the Assistance Coordination Unit (ACU), a body disbursing support to NGOs working cross-border in Syria, as well as the WHO’s small office in Gaziantep, which chairs the health cluster of NGOs working in the northwest. For years, these actors have largely operated autonomously, “each running their facilities as a fiefdom,” quipped a doctor in Idlib. 

The response to the pandemic in Idlib has been somewhat disjointed as well, but the NGOs did come together to establish a COVID-19 task force, which developed a PRP for Idlib with a budget of $30 million. An internal UN document shows that the area suffers from severe shortages of all the equipment needed to deal with the pandemic. Even this modest $30 million plan, which would allow the health care sector in Idlib to get up to a clearly inadequate baseline relying on the optimistic Wuhan model, now appears to have been shelved. The PRP was prepared in mid-March, and a month later, the WHO informed the NGOs in the health cluster that they should develop a Plan B based on their own existing capacities and aim to establish just one hospital-based isolation center with ten ICU beds and ventilators. The WHO is now trying to secure funding from the UN’s Syrian Cross-border Humanitarian Fund (SCHF) for the purchase of 90 ventilators, which would cost a fraction of the modest $30 million budget for the plan.

Moreover, Idlib’s limited testing ability had to be secured by the Syrian opposition, not the WHO. While the WHO quickly provided the Syrian Ministry of Health with five PCR machines, which are now able to carry out 100 tests per day, all of the machines are currently located in Damascus. When NGOs working in Idlib asked the WHO to provide them with a machine, they were told to send samples to Damascus instead, despite the regime’s track record of consistently withholding humanitarian aid and medical supplies from rebellious communities as a tool to force them to surrender. The PCR machine available in Idlib was eventually purchased by the opposition-linked ACU and is able to carry out up to 20 tests per day. “We feel that they are putting pressure on us to coordinate cross-line with Damascus. Slow movement of the Idlib PRP versus the PRP in Damascus moving quicker is one way to apply pressure,” said Dr. al-Omar of SAMS.

Idlib’s unique challenges and characteristics

While the entire health infrastructure in Syria will likely be overwhelmed by COVID-19, Idlib faces unique challenges. The Syrian regime and its allies routinely targeted ambulances, leading to an immense shortage. “Idlib’s health system does not have the capacity to get to all those requiring life-saving treatment,” said Khaldi of MSF. “What will happen is the situation in France, where they started counting people dying in elderly homes who were not reached before. In Idlib, many people can’t afford transportation. People will be dying in camps.” He went on, “It will be a nightmare trying to get to all these people with ambulances — [and] they will need to be disinfected after each patient,” further reducing the number of trips each ambulance can make.

Rebel-held Idlib is also incredibly small, making up just about three percent of Syria’s territory, but densely populated. If the expectations of experts that Idlib will be hit hard by COVID-19 come true, there will be a shortage of physical space for the mass graves needed. “There is a question of how to handle all the dead bodies we’ll have. We already struggle to find new places for camps. There is a shortage of land,” explained Khaldi of MSF. Electricity is cut off most of the day, but “we need [it] to keep the bodies at the hospital before sending them to the cemetery,” he added.

Idlib also has some characteristics that make it better prepared to deal with the pandemic than other parts of Syria. Hospital staff in the region are accustomed to working under extreme conditions, like shortages and airstrikes, and handling large numbers of patients that need to be quickly triaged, prioritizing who will receive treatment and who will be left to die. “Doctors here won’t mentally collapse like in other countries. We are used to seeing many patients die,” said Dr. al-Hiraki. The extraordinary dedication of staff in the region, who resume work only hours after their hospitals are bombed, can inspire some optimism too. Dr. al-Hiraki, whose family lives in Turkey and whom he hasn’t seen in two month, said: “When the regime was advancing toward the border [in late 2019], I told my family I will probably become trapped here and won’t be able to return. This is my duty to the people of the region.”

Photo by RAMI AL SAYED/AFP via Getty Images
Volunteers deliver aid at a camp for displaced Syrians near the town of Deir al-Ballut, by the border with Turkey, in Syria's Afrin region on April 14, 2020. Photo by RAMI AL SAYED/AFP via Getty Images

 

Turkish-controlled areas: Reliance on the foreign sponsor

The response to COVID-19 in northern Aleppo, Afrin (Efrîn), and the pocket between Tel Abyad and Ras al-Ayn (Serê Kaniyê‎) is largely coordinated and financed by Turkey. The area is under the control of the Turkish military and the Syrian Turkish-backed factions known as the “National Army” and is officially administered by the Syrian Interim Government. The latter has announced several steps to combat the spread of the virus, including canceling Friday prayers and closing schools and non-food shops. Turkish governors of cross-border provinces play a significant role in the administration of the area and the running of its health sector. Fewer NGOs operate in the region compared to Idlib due to Turkish restrictions and wariness on the part of NGOs about operating in an area where a foreign actor oversees the security sector and governance. 

The area is home to about 1.7 million civilians, most of them displaced from other parts of Syria. IDP camps dot the entire area, but many are located along the Turkish border. About 160,000 displaced persons live in regular camps and 130,000 in informal camps, all of them characterized by poor access to services and extreme overcrowding. The situation has only been exacerbated by the latest Syrian regime offensive on Idlib, which drove hundreds of thousands toward the Turkish-controlled areas.

The Turkish Ministry of Health is planning to set up two COVID-19 wards in the hospitals it runs in al-Rai and Azaz in northern Aleppo. COVID-19 samples taken in the area are analyzed in Turkey and thus far, have all tested negative. “The Turkish Ministry of Health plays a prominent role in the response in northern Aleppo, but it is overloaded with responding to the epidemic inside Turkey proper, so greater support is needed,” said Dr. Okba Doghem, the director of the health sector at the NGO the Syrian Association for Relief and Development (SRD), which works in northwest Syria and Afrin. 

Photo by Muhammed Said/Anadolu Agency via Getty Images
Children wear masks as a preventive measure against COVID-19 as Idlib Health Directorate and Civil Defense Crews along with local charities carry out disinfection works at schools and tent cities
in Idlib, Syria on March 18, 2020. Photo by Muhammed Said/Anadolu Agency via Getty Images

 

Conclusion

The devastation of Syria’s health sector — the damage done to its physical structures, the lack of equipment, and the mass flight of qualified physicians during the war — as well as the purposeful destruction of its health infrastructure by the Assad regime and its allies, and the efforts to starve the northeast of resources, leave Syrians incredibly vulnerable to the outbreak of the pandemic. While the country’s population is young, it is not healthy — many suffer from untreated conditions due to limited access to health care. Social distancing is not possible for most Syrians living in crowded apartments or camps, and neither is remaining at home for days without work. 

The COVID-19 response plan developed by the UN office in Damascus states that “the government is the natural leader for overall coordination and communication efforts,” concerning COVID-19 in areas under its control and in northeast Syria. The Syrian government, however, has consistently failed to prioritize the wellbeing and health of its citizens. The regime’s conduct since the start of the crisis indicates that its ultimate goal is maintaining control and weakening its opponents, even at the expense of Syrians’ health. The WHO is fully aware of this reality, yet prefers to maintain access and its working relationship with the regime rather than taking a public stand about the need for better access, setting clear red lines, or refusing to circulate and legitimize questionable data produced by the regime. This position extends beyond the WHO to other UN bodies, including the UN board of inquiry looking into a spate of hospital bombings in Idlib, which recently refused to name Russia as the culprit.

As the pandemic starts sweeping through Syria, the number of confirmed cases will likely remain significantly lower than the actual number of infections due to poor access to health services, low testing capacity, and fear among Syrians, particularly in regime-held areas, of seeking health care. The outbreak will likely have a debilitating and lasting impact on the country’s health sector, as the remaining doctors will be forced to treat patients without proper protective gear, while having a limited capacity to actually help critical cases. If medical professional become infected and die in large numbers, future health care provision will be further crippled for years to come.

The Syrian regime was already suffering from significant structural and economic weaknesses prior to the outbreak of the pandemic and the lockdown has only exacerbated things. While the day after the pandemic is hard to imagine even in stable and responsible democracies, what is clear is that in the months to come, Syrians will pay a heavy price for the corruption, stagnation, and destruction of the country’s health infrastructure, orchestrated by the regime now in charge of attempting to mitigate the impact of the pandemic on millions of Syrians. In the face of a crisis requiring a coordinated, coherent response reliant on highly skilled professionals, the communal solidarity and creative improvisation of Syrians, which got them through years of rule under dysfunctional or malign authorities, now appear utterly inadequate.

 

*All names of interviewees in regime-held Syria were changed to protect them from reprisal. 

Elizabeth Tsurkov is a Fellow at the Foreign Policy Research Institute focusing on the Levant. Follow her on Twitter @Elizrael. Qussai Jukhadar is the pen name of a Syrian researcher based in Turkey. Follow him on Twitter @Qussai_jukhadar. The views expressed in this article are their own.

The authors would like to thank Dr. Omar al-Hiraki for generously providing his medical expertise, which greatly assisted in the writing of this analysis.

Photo by AAREF WATAD/AFP via Getty Images