The impact of coronavirus on Syria

16th April 2020: A report by The Syria Campaign for the International Development Committee’s inquiry ‘Humanitarian crises monitoring: impact of coronavirus’

About The Syria Campaign

The Syria Campaign is a human rights organisation that supports Syria’s courageous frontline humanitarians and activists in their struggle for freedom and democracy. The Syria Campaign is independent and we have not taken money from governments or individuals linked to the violence of the conflict. All our donors have strong commitments to democracy and human rights – the values that drive our work.

Introduction

This report details the extreme challenges that Syrians face in addressing the coronavirus pandemic.

Principally, Syria’s medical infrastructure has been devastated after 9 years of conflict and the deliberate and strategic targeting of medical facilities by Russia and the Syrian regime. Out of the total 111 public hospitals in Syria, only 58 are fully functioning. Up to 70% of health workers left the country as migrants or refugees. Since 2011, 595 attacks were conducted on at least 350 separate health facilities, and 923 medical personnel were killed. 536 of these 595 attacks were conducted by the Syrian regime and its allies[1]. Throughout Syria, healthcare workers with inadequate personal protective equipment (PPE) are particularly at risk of coronavirus. Syria’s Northeast is severely lacking the medical infrastructure to treat a coronavirus outbreak.

Prior to the global outbreak of COVID-19, civilians in Idlib in Syria’s Northwest were already living through the worst humanitarian crisis of the 21st Century. Since December 2019, over 1 million people have been displaced by an intense aerial offensive by Russia and the Syrian regime. Despite the decrease in hostilities after a ceasefire on 6 March, humanitarian needs for nearly 4 million people in Idlib and northern Aleppo remain severe. Fear of the conflict restarting, and the fact that entire towns were destroyed by the bombardment, is preventing civilians from returning home.

For the 100,000 Syrian’s detained in Assad’s underground detention cells, the risk of death from coronavirus is severe. But instead of releasing prisoners, or providing access to the ICRC to provide medical and hygiene support, there are reports from regime-held Syria that doctors have been threatened with detention for just reporting cases of COVID-19. Further inept governance is putting citizens at risk: last month the regime gave government employees residing in Damascus suburbs - what is known to be the reconciled areas - only two hours to collect their wage packets which resulted in crowds of people at dedicated cash machines.

Civilians desperately need the international community to protect the ceasefire so they can return home, to step up aid to Idlib and Syria’s Northeast, and to push for the release of all detainees.

Confirmed cases in Syria

As of 14 April, there were only 25 confirmed COVID-19 cases in Syria, with two deaths. All positive cases to date have been in regime-controlled areas and stem from 950 tests conducted through the Central Public Health Laboratory (CPHL) in Damascus as of April 10. Testing capacity by the regime has reached 100 tests per day, from a previous rate of 30 per day[2].

Medics in Syria suspect there may be many more cases[3] and there have been independent reports of coronavirus-like cases in Damascus, Tartus, Latakia, Homs and Deir-Ezzor[4]. Before they admitted to the first case, the regime threatened doctors not to report Corona cases in Damascus[5].

In Idlib, outside of regime control, 120 tests have all come back negative, but the areas’ single testing machine is not sufficient to test a higher volume of samples[6]. With cases in neighbouring countries and in Damascus, and given the conditions in camps, it is only a matter of time before people start losing their lives. Refugees International told The Independent at least three people in Idlib have died showing symptoms of Covid-19, and several other patients had been quarantined[7]. Throughout Syria a lack of capacity to test for coronavirus and huge barriers of access to medical facilities make it extremely difficult to gauge the true extent of existing cases.

Researchers at LSE have calculated that the maximum number of COVID-19 cases that could be adequately treated in Syria is currently 6,500, based on 325 available Intensive Care Unit beds with ventilators across Syria, where approximately 5% of the total COVID-19 cases would require critical care. Once the number of cases passes 6,500, the healthcare system is likely to collapse. Capacity varies considerably within Syria, from 1920 (Damascus) to 0 (Deir ez-Zor)[8].

The response by the World Health Organization (WHO) has been too slow.

What are the challenges for civilians in Idlib’s displacement camps?

Conditions in Idlib’s 400% overcapacity displacement camps make it almost impossible for civilians to follow WHO guidelines on preventing the spread of coronavirus, from social isolation and social distancing to hand washing. Many tents house at least 10 people and it is not realistic to ask people to stay inside.

There is a lack of concrete housing, sanitation and water infrastructures. The UN’s OCHA estimates that 290,000 people’s shelter will be affected by the slowdown in operations between March and May; and 2,650,000 people will be affected by WASH interventions being suspended or constrained due to movement restrictions[9].

A displacement camp in Idlib, Credit: Bonyan Organization 13th April

Hundreds of thousands of civilians are malnourished or have underlying health issues after spending months in camps over a freezing winter where the temperature dropped to minus 7 degrees on some nights. Respiratory infections were a widespread problem in camps this winter and dozens were reported to have died of the cold. Three in every 10 children under the age of 5 years are stunted and acute malnutrition among women is reportedly increasing[10]. There is a high prevalence of non-communicable diseases in IPD populations[11]. Years of war, sieges, chemical attacks, malnutrition, depression and anxiety have left a considerable proportion of the population with a weakened immune system[12].

At least 1 million children are missing out on education in camps. These children were already not in schools due to this year’s bombardment. Protection concerns for women were already recorded by civil society groups, and many now fear the effects of lockdown measures on domestic violence and sexual exploitation in return for aid.

Civilians can’t return home. As the tentative peace holds, displaced Syrians are weighing up grim options: remain in tightly packed camps with few services where a viral spread could be lethal, or return to homes still at risk of getting caught in renewed bloodshed. The White Helmets are helping some families to return to their villages like Ariha and western Aleppo countryside that are now on the front lines, however there are no utilities or healthcare for the population. The majority of displaced (including 280k from Maarat Al Numan alone) still can't return home, which is why we are calling for the regime to go back to Sochi lines.

Idlib’s medical infrastructure has been decimated by years of deliberate and systematic bombardment by Russia and the Syrian regime and medical supplies are scarce or non-existent.

●        There are only 3065 hospital beds in Northwest Syria for a population of over 4 million. That is only one hospital bed for every 1363 people, and in Idlib city there is only one hospital bed per 1592 citizens.

●        There are only 201 intensive care beds, and only 95 ventilators. None of the ventilators are vacant as almost all of the beds are already being used by patients with serious illnesses[13].

●        There are only 600 doctors in northwest Syria to serve 4 million civilians, including more than one million displaced.

The Idlib Health Directorate has warned that 100,000 people might die in northwest Syria unless the World Health Organisation provides urgently-needed ventilators, protective gear for medical staff and hand sanitiser to camps.

“In one year, we lost around 76 health facilities in northwest Syria. Donors have cut their funds and medical staff have been killed, arrested or displaced. The health sector in Idlib cannot cope with the inevitable outbreak and we fear 100,000 people could die unless we get supplies immediately.

“Our ventilators are always 100% occupied and we don’t have one single bed ready for a Corona case today. Camps are the perfect breeding ground for the virus and 400% overcapacity, with ten or more people sharing one tent. People don’t have enough water for drinking, let alone washing their hands.”

Dr Munzer al-Khalil, Head of Idlib’s Health Directorate

Health emergency response plans in Northwest Syria are usually implemented by Syrian medical NGOs and the Idlib Health Directorate (IHD), a quasi-state local governance structure established by local doctors and NGOs. Both the medical NGOs and the IHD are chronically under-staffed and underfunded. Under pressure from the IHD, the WHO has eventually sent testing kits to Idlib. They initially tried to make IHD receive testing kits from Damascus, but did in the end agree to send 5000 kits to the Northwest via the Turkish government.

White Helmets COVID-19 response plan, Credit: White Helmets, 13th April

Adnan Kiwan hospital, which was hit during airstikes in the town of Kansafrah, in the south of Syria's Idlib province in November, Credit: New York Times

The OCHA reports that US$ 500m of emergency funding is required for Northwest Syria to provide humanitarian assistance to 1.1 million people until July 2020, and US$30m is needed for the COVID-19 Readiness and Response Plan[15]. Border restrictions and a deteriorating economy present growing challenges to procuring essential supplies.

What are the challenges for Syrians held in detention centres?

Across Syria, approximately 100,000 detainees are being held in squalid, unventilated cells in underground prisons with no access to healthcare[16]. Their immune systems are exhausted by the regime’s systemic torture, starvation and mistreatment[17]. In 2014 Caesar, a former military police officer, shocked the world when he exposed photos of the true depravity of Assad’s cells. He produced pictures of at least 6,700 bone-thin corpses, and testified to the disease-ridden conditions. If coronavirus spreads amongst detainees, it will be horror beyond imagination.

Amongst the detainees are 3327 medical workers who have been detained or disappeared. Their expertise is desperately needed in the fight against COVID-19 in a country with a shattered health system. The families of Syrian detainees are calling for the urgent release of detainees[18].

Arbitrary detention, forced disappearance and torture with impunity remain widespread across Syria. According to the Syrian Network for Human Rights (SNHR), 982 men, 96 women and 78 children who were detained or forcibly disappeared in Eastern Ghouta near Damascus between April 2018 and February 2020 remain unaccounted for. They went missing after signing so-called reconciliation agreements. SNHR has documented the arbitrary arrest incommunicado of at least 63 individuals including 17 children, by Syrian regime forces on the basis of the imposed lockdown mainly in the governorates of Damascus, Hama, Deir Ez-Zour, and Aleppo, showing that the regime is using the harsh realities of the global pandemic to punish those it wants locked up.

“As Syria’s incredible medical staff work in the most impossible conditions to save lives and prepare communities for the inevitable increase in Coronavirus cases, they work in the knowledge that thousands of their colleagues have been sentenced to the horrors of Assad’s infamous jails. Colleagues who, alongside approximately 100,000 other civilians and peaceful activists illegally detained by the regime, are held in cramped crowded cells without proper food, drinking water, hygiene or medical care. If coronavirus spreads containment will be impossible.”

Dr Hala Al-Ghawi of Families for Freedom, a movement for families with loved ones in detention

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“Syria’s detainees are stuck in tight cells, sharing the torture, hunger, pain and diseases. My son and his colleagues who were arbitrarily arrested from Damascus Faculty of Medicine were health workers who were detained for providing healthcare to those who needed it. They were tortured and denied medical care. Today, we can’t even imagine what will happen if COVID-19 spreads in the Syrian regime’s detention centres. Tens of thousands are in danger, including medical workers, who should be free with their families, doing their jobs supporting their communities in these dark times.”

Mariam Alhallak, Chairperson of the Caesar Families Association, whose son was killed for his work as a doctor in 2012.

The UN Special Envoy for Syria must demand the immediate release of all detainees held in Assad’s prisons and unofficial detention centres. At the very least, international health organisations, such as the ICRC and WHO, must have regular access to the official and unofficial detention facilities in order to provide critical sanitary measures and medical treatment to detainees.

What are the challenges in Syria’s Northeast?

Over 4 million people are currently living in northeast Syria (NES), consisting of the provinces of al Raqqa, Deir ez-Zor and al-Hasakah, where the medical infrastructure is incapable of responding to scale.  Only one of 16 hospitals in the region is fully functional. Two additional hospitals identified to quarantine and treat patients are underequipped, with only 28 beds for intensive care, 11 ventilators, and two doctors trained to use them[19]. 18 of these ICU beds are located in the province of al-Hasakah (including the city of alQamishli) and 4 are in al-Raqqa, with none available in Deir ez-Zor[20].

There are also more than 600,000 internally-displaced people (IDPs) in NES, 200,000 of whom were displaced since October 2019 as a result of Turkish military operation. Around 100,000 of the internally displaced population are being housed in IDP camps and all education facilities in the region are closed[21]. Cross-border provision of medical supplies is becoming almost impossible.

Ongoing disputes between Turkish-held groups and the SDF are exacerbating the situation. On March 24, Turkish-backed groups shut off water to the city of Al-Hasakeh, creating increased risks of coronavirus and other disease outbreaks for some 460,000 residents, including tens of thousands living in the Al-Hol displacement camp[22].

What are the challenges in regime-held Syria?

The Syrian regime announced sweeping measures on March 15 to combat the spread of the coronavirus, closing universities, schools, government offices, restaurants and markets, as well as shutting down all intercity public transportation across the country, and imposing a curfew from 6pm to 6am. On 2 April, a weekend curfew commenced, from 12pm to 6am every Friday and Saturday[23]. Assad’s quarantine measures are leaving millions without daily wages and proper health and social care, as most people’s livelihoods depend on day labour and they do not have a safety net.

But despite pressuring civilians through its security agents, police and military in the streets; the regime itself is proving inept at responding to the risks of coronavirus. Last month government employees residing in Damascus Suburbs (mainly areas that signed reconciliation agreements with the regime) were given only a two hour window to cash their salaries from dedicated cash machines, which resulted in long queues and crowds putting the lives of its own public sector servants at risk. And every day hundreds of people gather for hours to wait for bread at distribution points. In some cases, fights have broken out in desperate attempts to feed their families[24].

Despite the delivery of several testing kits by the WHO to the public hospitals in the government-controlled areas, several sources confirmed that some public hospitals, such as al-Mujtahid hospital in Damascus, are asking patients to pay up to 50,000 SYP (approx. 50 USD) per test; this is greater than many people’s monthly salary[25]. If the past nine years is any indication, the regime is unlikely to be moved by its people’s suffering and act to save their lives.

What are the specific challenges related to education?

What are the challenges surrounding the Syrian economy?

Since January the value of the Syrian pound – last year trading at 500 to the dollar – has dropped off a cliff, reaching a record low of 1,360 to the dollar on the black market in late March. As a result, inflation and the cost of basic goods are soaring. According to a UN report from 2019, 83% of people across both government and rebel parts of the country were already living in poverty[26].

What are the issues surrounding the coronavirus response?

There are emerging issues around transparency and coordination of the coronavirus response in Syria. Inside Syria, the regime and de facto authorities will not coordinate the response to the pandemic, even though the virus will not discriminate by geography[27]. The World Health Organisation traditionally deals with state bodies, but a successful response inside and outside Syria will require coordination with a multitude of entities and actors.

Recommendations to the UK Government:

●        Britain and other governments must protect the fragile ceasefire between Russia and Turkey in Northwest Syria, and demand that the regime returns to Sochi lines, so that the 1 million people displaced from their homes since December can return to their towns and villages. Attempts to social distance and stop the spread of coronavirus in Idlib’s 400% overcrowded displacement camps are almost impossible in current conditions.

●        Bolster the government’s aid - and put pressure on the WHO to improve their coronavirus response - to Northwest Syria, where the medical infrastructure has been destroyed by years of deliberate targeting by Russia and the Syrian regime. The World Health Organisation must provide urgently-needed testing kits, ventilators, hygiene kits, and ICU unit equipment, protective gear for medical staff and hand sanitiser to overcrowded camps. Donors should ease procedures of funding or reallocate existing grants for local CSOs inside Syria so they can respond rapidly to support communities and health authorities.

●        Pressure the UN Special Envoy for Syria to demand the immediate release of all detainees held in Assad’s prisons and unofficial detention centres. At the very least, support international health organisations, such as the WHO, to have regular access to detention facilities so they can provide critical sanitary measures and medical treatment to detainees.

●        Support civil society and community organisations with much-needed funding and treat civil society as an essential partner. Syrian civil society has the potential to play a vital role in responding to this crisis. This is particularly the case in the northwest of the country, where medical Syrian NGOs are leading the fight against the virus.

We would be happy to provide oral evidence, or to help arrange for our partners in Syria including the White Helmets to give evidence.

Please contact Rebecca Falcon, campaign manager at The Syria Campaign, for further information on rebecca@thesyriacampaign.org