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.