RECOMMENDATIONS

We urge the international community and INGOs to acknowledge the unattainability in applying the basic COVID-19 preventive measures. inside Syria, camps in neighbouring countries and in Europe). After extensive consultations with our members and partners, we have accumulated the following recommendations that we address to different bodies :

              TO PARTIES TO THE CONFLICT:

First and foremost, we demand that conflicting parties, regional and international powers heed the call of the UN Secretary-General to cease fire and give health systems a chance to fight the pandemic,  a virus that knows no boundaries, ideology, religion or ethnicity as a universal humanitarian and humane duty.

              TO THE WORLD HEALTH ORGANISATION:

•      Immediately support hospitals, isolation centers, and camp medical centers with testing kits, ventilators,  hygiene kits, and ICU unit equipment. Provide personal protective equipment  (PPE) in sufficient numbers to cover the needs of medical staff, NGO workers, logistics workers, and local journalists;

•      Implement a realistic response to the pandemic and start working with internationally accepted local authorities in Northeast and Northwest Syria who implement health services;

•      Ensure that Syrian CSOs including health CSOs and medical workers are around the table in any discussion around the response.
 

              TO DONORS:

•      Coordinate with de facto authorities and not solely the government in order to accelerate the dissemination of information, material and staff;

•      Ease procedures of funding or reallocation of existing grants for local CSOs inside Syria and those working in refugees camps in neighboring countries for rapid response projects providing support to communities and  health authorities to respond to the pandemic;

•      Support addressing the impact of the pandemic though financial support and livelihood so families can be lockdown without fear of hunger;

•      Support local CSOs in providing remote education to children;

•      Support local CSOs responding to social risks caused by social distancing.
 

              TO THE INTERNATIONAL COMMUNITY:

•      Ensure that sanctions and restrictive measures imposed by governments contain exemptions for the provision of goods and services relevant to the COVID-19 response, and ensure that exemptions already in place are effective and utilised;

•      Reassess the legitimacy of sanctions affecting the health sector and civilian lives after the end of the pandemic;

•      Ensure a special dispensation that enables WHO to work with regions of Syria, and not only “states”;

•      Ensure coordination with all authorities across Syria to distribute materials and equipment in a fair manner on the basis of a needs assessment.
 

              TO AUTHORITIES IN REFUGEE HOST COUNTRIES:

•      Anounce that infection with the virus does not equal deportation or arrest for undocumented Syrians. This must be monitored to ensure this crisis doesn’t indeed provide a license for authorities to deport Syrians;

•      Improve the sanitary conditions for all refugees, migrants and displaced people;

•      Suspend evictions of refugees during the outbreak.
 

              TO SYRIAN AND INTERNATIONAL NGOs:

•      Implement a high-level task force: a cross-regional approach, with global support and a multidisciplinary task force (doctors, policemen, CSOs, local councils, etc.) with local authorities and “correspondents” to apply and monitor this approach and work at a local level;

•      Provide factual information about all areas of Syria in order to evaluate the needs and the evolution of the sanitary crisis;

•      Ensure that support provided by donors to tackle the crisis reaches all areas of Syria;

•      Funds and in-kind donations should be monitored to ensure they reach the designated project. Emphasis on transparency is vital for trust purposes in the public health system and the interest of donor’s;

•      Key information should be made available on how to protect oneself, for those with little to no resources, who don’t speak additional languages;

•      Ensure an unbiased and transparent coverage of the epidemic in all areas with a focus on the people affected by it;

•      Provide population and specifically women  with access to psychosocial support and creative solutions to boost it, including through technology such as text messaging or online platforms.
 

ACROSS SYRIA

KEY CHALLENGES AND CONCERNS

A broken healthcare system

Syria’s broken healthcare system is a result of almost a decade of a highly destructive war.. According to the WHO, only 64% of hospitals across Syria and 52% of primary healthcare centers were functional at the end of 2019[1]. According to this document, up to 70% of the health workforce is known to have left the country. The lack of human resources, access restrictions, and the deliberate mass attacks on health facilities have paralyzed healthcare in Syria. The lack of basic health infrastructure on a national level raises concerns for the  civil society about the management of a highly possible COVID-19 breakout. In Syria, the figures of Covid-19 casualties we’ve seen globally will undoubtedly be more dramatic. The global shortage in medical and personal protective equipment (PPE) and the competition with developed countries for the existing supplies will make it all the more challenging for the Syrian health system to deal with Coronavirus. One of our members raised the point that harvest time is coming soon and is accompanied by an increase of dust in the air, which usually results in an increase in respiratory illnesses. These might put extra pressure on doctors and hospitals with people showing up with symptoms similar to COVID-19.

Lack of capacity to test 

The issue of carrying out tests is crucial in Syria as everywhere around the world. Until today, tests are lacking in Syria, with only a few hundreds of tests provided by the WHO. Dr. Chamsy Sarkis, former scientist in Molecular Biology and virology at the CNRS in France told us during an interview: “It is time the WHO recognizes that dealing with Coronavirus  in Syria without a reasonable amount of tests is like  sending a blindfolded surgeon to the operation room. This is very alarming, as more and more people across the country complain of symptoms similar to those of COVID-19”.

All of our interviewed members fear that Syria doesn’t have sufficient expertise and equipment to develop tests for COVID-19, thus relying on WHO to provide tests, which are  insufficient. According to local sources, only a few hundred tests have been provided for the north of the country, which has only one PCR machine to perform the tests. The same PCR machine is of poor quality, not suitable for large scale testing, as it allows only ten  PCRs in parallel, which means only eight tests, as two slots of the machine are needed for positive and negative controls. Dr. Sarkis told us “The WHO is not thinking the right way in Syria. Syria will not compete with rich countries to  access the  WHO RT-PCR test kits. The WHO and donors should provide means to set up makeshift laboratories, be able to perform common RT-PCRs with cheaper reagents and with high throughput capabilities. Some Syrians abroad do have the necessary expertise to set up and run such facilities, and some are ready to go to Syria for such a mission. Most importantly, the WHO and donors should guarantee hundreds of thousands of rapid immunoassay tests for Syria, the most suited solution for mass testing in the country . Without extensive  testing, we will act blindly, thus probably wrongly.”

A high proportion of vulnerable people

Two populations are particularly vulnerable to COVID-19: the elderly, and people  presenting pre-existing health conditions (diabetes, hypertension, cardiovascular diseases, cancer). The mortality rate of vulnerable groups may rise to 20% or even more, according to worldwide scientific and medical literature[2]. Moreover, both international and local NGOs have warned about the high prevalence of non-communicable diseases in refugee populations inside and outside Syria[3]. Most prevalent are diabetes, hypertension, and cardiovascular diseases, the same pre-conditions making people much more vulnerable to Coronavirus lethality, at up to tenfold, even 100 fold higher than people in good condition from the same age category. Although updated and accurate statistics are not available, members of our coalition working with refugees and IDP camps, all agree that the prevalence of pre-existing health conditions raising vulnerability to COVID-19 are high in these populations, and increasing overtime for the last years, due to lack of health care.

Although the population age pyramid in Syria is on the younger end of the spectrum, nine years of war have led the country’s demography to change. Over 5.6 million people have fled the country and many young men have largely been killed or arrested. The average age of the population is now older than in 2011. In such circumstances, Syrian civil society organisations are now concerned that the virus outbreak could  lead to a large  number of deaths among the older generation within the country. 

Over the years of war, sieges, chemical attacks, malnutrition, depression and anxiety have left a considerable proportion of the population now with a weakened immune system which makes them more fragile or vulnerable regardless of their age.

The scale of forced displacement is an additional serious risk factor for millions of Syrians, increasing their vulnerability to the pandemic. Most of the people internally displaced are living in terrible conditions, some in informal settlements, without adequate shelter and with minimal access to food, health and education. 

The large-scale arbitrary detention and forced disappearance of thousands of men, women and children whose lives have been in limbo for years, is also a risk factor. Syrian CSOs are very much concerned about the estimated 90,212 detainees (according to the Violations Documentation Center in Syria and the Syrian Center for Media and Freedom of Expression) who are being denied any medical care. 

Extensive forced military conscription also contributes to the population’s vulnerability to COVID-19. Not only are young men being sent to die, but households have been economically challenged and thus made vulnerable, restricting many families’ access to food, health, and education. 

One of our members mentioned an additional risk related to health habits and behaviours of Syrians: “Syrians are used to taking antibiotics, and strong medicine that we can buy very easily in pharmacies. Elsewhere people aren’t allowed to buy such drugs without a prescription. These habits have weakened our immune system over the years. Furthermore, some of these drugs can have hazardous side effects if the patient is infected with COVID-19. This is a cultural problem that will also play a major role in this crisis.”

Photo credit: Half Of Syria, “Child in a camp. Ariha, Idlib”

No safety net in a broken economy

Inside Syria, people cannot afford to stay at home and adopt the lockdown measures that would slow the spread of the virus. Most people’s livelihoods depend on day labour, and they do not have a safety net. According to a member of Half of Syria, the cost of staple goods  makes up at least 80% of an unskilled worker’s monthly salary, and 50% to 80% of a public service worker’s monthly salary: these are the “working poor” in Syria. At the time  of writing, the daily wage for 12 hours typical daily labour in Idlib is 1,500 Syrian Pounds, about 1.10 Euros. The effects of a COVID-19 outbreak will aggravate the already-ongoing economic decline, further reducing households’ purchasing power and access to health. According to the UN OCHA’s Humanitarian Needs Overview (HNO) in 2019[4], 83% of Syrians live below the poverty line. This leads many Syrians to adopt “harmful coping strategies” such as reducing their food consumption, ignoring medical needs, or even reducing hygiene practices. There is no support system for many people and their families.

One of our members who we interviewed told us : “All the countries are facing this crisis not only from a health and medical perspective but also from an economic one. States are providing support mechanisms to encourage their citizens to stay home and respect security measures. This is something that won’t ever happen in Syria. There is no economic policy to support people and encourage them to respect a lockdown”. Local administrations and authorities don't have the capacity to support small businesses. Civil society organisations in general were concerned that very few people can work from home or can afford to spend a few weeks without working. One of our contributors  said , “It is easy for us to stay home and work remotely on our laptops, but this can not be considered by the vast majority of the Syrian people inside the country”.

Lack of awareness

Several local associates expressed their concerns at the overall lack of awareness among citizens. One of our interviewed members told us that “it seems like people all over the country still do not grasp  the nature of the virus, how rapidly it spreads and why it is crucial to flatten the curve urgently.  Independently from the current context related to the ongoing war, Syrians, like many other people in the region, are usually socially very close, and the individual sphere is tight.” Syria has a close-knit society with intimate social relations within its communities, as in neighbouring countries. Dr. Sarkis, also expressed concern about this and said during an interview that “it seems like people are not taking into consideration the speed,the high  contagiousness of the virus, and a policy on social distancing  will be tough to set up in Syria. One should recognize that social distancing will not be feasible in some parts of Syria, and alternate strategies must be thought and implemented to secure the most vulnerable”. 

An important factor in mitigating any public health crisis is people's ability to stay connected, aware, and informed through the internet. One of our members, in a yet unpublished report, has found that at least 90% of households in rural areas and in IDP camps (a tent is considered as a household) have access to a smartphone and use the internet for at least one hour per day. In 2019, when the research was performed, households spent up to 30% of their income on Internet communication, mainly in order to have access to news and to communicate with relatives. In the condition of an outbreak, with the probable increase in the price of basic service and with higher health and hygiene spending, many may need to reduce their spending on internet access. Consequently, access to information and guidance  on COVID-19 might be reduced, even more for isolated populations, such as in informal camps. Risk communication, a field of action identified as crucial by WHO in the battle against Coronavirus, will thus be less effective when many Syrian households, especially the poorest, cannot afford to spend money on internet access.

Lack of transparency & coordination 

The members of Half of Syria noted a strong concern related to the coordination of a response to the COVID-19 pandemic. Coordination and transparency are lacking on several levels: within the country between different areas, between the regime and the Syrian people, and between UN organisations working in Syria, and Syrian CSOs.

These  circumstances make it difficult to cooperate with INGOs since there is no unity in the country to establish an action plan across the country. For instance, several members denounced that the WHO does not deal with regions, but only with states. The WHO is refusing to deal with regions in  Syria is problematic. “There needs to be a proper adapted plan, in both regime-held areas and the others. We lack leaders who own the responsibility to pilot the response”, said a spokesperson for a local member organisation.

The lack of cooperation between different areas of the country constitutes a big challenge for Syria. One Half of Syria member said that the virus would hit the Syrian territory in its entirety. As a result of the conflict, the country is divided into different areas with different military or political factions governing their territory. The factions are at war, and inevitably, this  results  in a lack of coordination between the different areas. “This is a pandemic. You can't treat the problem in each area separately, because people move from one area to another constantly. Even if you focus on one area and manage to contain the virus, if you don't coordinate with other areas, you won't be able to sustainably contain it” she explained. Another member’s focal point expressed similar concerns. Every country is handling the Coronavirus crisis as a state, which can not be the case in Syria given the country’s governance division. There is no united governing force that can act as a leader for the country, and ensure that citizens across the country apply restrictions and measures. 

Half of Syria member organisations expressed that  UN agencies working in Syria are not working transparently, or adequately, with many Syrian NGOs. The Health Cluster in Gaziantep has a COVID-19 Task Force that coordinates the health response, and UNOCHA has supported the Inter-Cluster Coordination Group (ICCG) to create a response plan[5]. Although essential, coordination with Clusters is not sufficient, as many local NGOs inside Syria and Syrian NGOs abroad are not within the Clusters, although they are providing crucial support to many communities or sectors. One of our members explains, “I do not understand how these Clusters interact with the UN. I sometimes read nonsense proposals produced by UNOCHA and WHO, when dealing with Syria. For example, a recent UNOCHA report states that “some IDP families are using public buildings as collective centers, including some schools that need to be evacuated to resume educational activities” when we believe that schools need to be used to shelter the most vulnerable in an epidemic situation, and indeed not reopened.”

Several members and partners highlighted the importance of a Syrian-led task force, which the UN should collaborate with, to deal with the parts of Syria that are not under the control of the Syrian government. Another member stated, “grassroots organisations will be at the frontline in the COVID-19 response, and they should be listened to immediately before it is too late”. Referring to the UN, he adds: “Once the big whale takes a direction, it will be too late to change it, even if it is speeding straight to the shore”.

The impact on women

According to a Half of Syria member, women and children make up 80% of the population of displaced persons in Syria. As well as the vulnerabilities of displacement and the effects that may have on their health, the COVID-19 pandemic poses a wealth of increased protection risks for women. This member organisation working on the empowerment of women said “We receive a lot of questions from women, on how to clean vegetables and how to disinfect tents. They are scared and worried about how they will protect their families. Some women are trying to produce their own disinfectant solution by mixing chlorine with other cleaners, which can produce dangerous reactions. We have heard of several cases of poisoning in Damascus, Idlib and in neighbouring countries, all of them women”.

The economic impact of lockdown measures also pose a threat. Prices of basic foodstuffs and sanitation products have risen, according to the same organisation. Women risk being exploited, and the organisation had previously heard of cases where women were sexually exploited in exchange for aid. In times of scarcity, women are often the last person in the family to eat, despite at times being the person who may need nutrition the most because they are pregnant, breastfeeding or menstruating. 

Women bear the burden of childcare, which has increased in many cases due to the closure of education facilities. In camps, informal settlements and apartments, women must educate, entertain and protect children in already difficult living circumstances.The impact of the outbreak on the mental health of women cannot be overstated. In addition to their own stress, women need to deal with their children’s anxieties and confusion; for example, many of them don’t understand why they can not go to school anymore. Access to psychosocial support will no doubt be affected.

Within the Ebola outbreak, researchers found that the outbreak had a negative impact on sexual and reproductive rights, with all health resources diverted to combating the outbreak. In The Atlantic quoted a researcher saying “Things that aren’t priorities get canceled. That can have an effect on maternal mortality, or access to contraception.”[6] In Syria we already have witnessed raising of maternal mortality during birth due to the war, we are very afraid of a new raise. 

Domestic abuse was a serious cause for concern during the pandemic. In contexts where the rule of law and a justice system was absent, women were at great physical risk during lockdown. The head of one feminist organisation said, “I have personally received jokes that say it is time to take revenge from women as the police will not come to your place”. According to Lebanese organisation Kafa, reports of domestic violence increased by 100%[7] since the beginning of the lockdown in Lebanon and Syrian refugee women are now less likely to report  abuse as they have less access to communication tools due to the lockdown. 

In Syria, like elsewhere, women are responders to the pandemic through their professions, in particular nurses and teachers. Although they are now needed more than ever, no support system exists in place for them. A lack of protective gear poses a risk to women and their families, and though they are expected to respond to the crisis, they had no access to childcare or mental health support. The partner organisation quoted said they were looking for ways to support women through the organisation. Led by Syrian women to support Syrian women, the organisation’s model of work includes a focus on establishing safe spaces for women to meet, make use of services, receive psychosocial support, access to internet and training in the English language or other skills. This model is unfeasible during the pandemic and the organisation was exploring alternatives.

An international crisis

Due to the nature of the pandemic, countries all over the world are struggling to deal with their health and economic crises at a national level and are, in some cases, calling for help from other nations and INGOs. One of our member organisations, specialised in child protection and education, explained during an interview that Syria, despite its catastrophic humanitarian crisis and urgent need for support, is not the international community’s priority. He said, “The problem is global so there is a disinterest in the Syria file. Donor countries are so overwhelmed. Look at the situation in France. In Germany, Syria is not a priority at the moment.”

Sanctions and restrictions

"We need to take a clear stance on sanctions. It is vital to note that there are many reasons behind further poverty in Syria. If America is going to force sanctions on Syria, they're welcome to put sanctions against the regime. But the sanctions and restrictions put on an entire country also impact the support that aid agencies can provide. Advocates need to ensure the message that sanctions should not include health sectors - if an entire country has a sanction, it will make it even more difficult for banks to deal with it. We can't be restricted any more than we are on delivering aid in Syria." said one of our members. This shall be done with great consideration to the fact that the Syrian regime is politicising the issue and trying to get the sanctions applied on it lifted, out of this pandemic. 

SYRIAN REGIME-HELD AREAS

Photo credit: SMART News Agency, « Ain Tarma with Curfew »

KEY CHALLENGES AND CONCERNS

Opacity and denial

Despite the regime’s attempt at denying any critical risk, there are many reasons to fear that the virus is spreading within the country: Pakistani authorities reported that the country’s first cases were fighters coming back from Syrian regime-held territories inside the country while the regime was still denying the presence of COVID-19 in its territory[8]. Furthermore, Iran, which has been  harshly affected by the pandemic, has thousands of its fighters supporting Assad’s regime locally[9]. However, despite those reasons and the increasing number of people complaining about symptoms (mostly as “pulmonary infections” according to a local member), the regime does not provide a transparent discourse on the situation and is not sharing updates about the number of people infected. On  the contrary: it tries to stifle any case or proof of the outbreak and to shut down any public announcement related to the pandemic, even when it is coming from the medical community (as explained by Mazen Ghabirah and Zaki Mehchy in their research “COVID-19 pandemic: Syria’s response and healthcare capacity[10]”). The first official case of COVID-19 was declared only on March 22nd, when there were reasons to believe that there have been many more cases for quite some time before.

The regime is dealing with the pandemic with opacity. Dr. Joseph Daher,  an academic whom we have interviewed, pointed out that the regime is trying to block any independent solidarity initiative coming from citizens. “The regime wants to prevent any autonomous and local solidarity initiative to develop its means of self-organisation and expand its own networks. We have seen many local solidarity initiatives flourishing in some cities in regime-held areas, a lot of them having started on social media . In Damascus, Tartous, Lattakia, Sweida and other cities, these local initiatives aimed at helping  people in need, raising awareness and providing means to prevent spreading the virus, delivering food and medicine for vulnerable citizens , among others. However, the Minister of Social Affairs and Labour stated that people should provide aid exclusively through the entities registered with the Ministry”. This is how for instance, some local youth initiatives in Lattakia have been repressed by security forces, according to the academic. 

Fear of interrogation

As a result of the regime’s repression, patients may be  afraid to report their symptoms. One local member, said that citizens in regime-held areas are experiencing an additional level of stress with this outbreak - the  fear of being interrogated. There is a real taboo around COVID-19 in Syria. This is cause for concern, given that when people don’t speak up about their symptoms, they are unable to access treatment  and may be spreading the virus among their community. Taboo is a consequent factor of the propagation of the virus in Syria. 

LOCAL RESPONSES

It is clear, from our interviews with members and associates , that in regime-held areas, populations mostly have to rely on themselves and can not expect proper protective measures from the government’s system. According to the aforementioned research carried out by Mazen Gharibeh and Zeki Mehchy, patients are relying on informal personal connections to get tested or to be admitted to hospitals. Some private hospitals are also offering the test for approximately 300 USD for the minority able to afford the sum. In this report, they highlight that one of the most significant efforts put in place by the Syrian regime since the propagation of Coronavirus is to bury the stories and suspicions of cases, rather than responding to an outbreak within the country. The regime is not attempting to cooperate with other regions of the country to set up a global plan in Syria; authorities in general are wary of cooperating together. Therefore, responsible measures are mostly taken by people themselves, at an individual level, as much as possible. As Dr. Daher told us, some local citizens' initiatives are emerging from people in regime-held areas, to try to provide help to vulnerable populations. These initiatives have flourished in Damascus, Lattakia, Tartous, Sweida, Hama, Homs, Aleppo and Deraa. Most of these initiatives consist in bringing assistance to people in need, securing them and delivering food and medicine for them, especially the elderly. Some local NGOs and associations also initiated campaigns to raise awareness and provide means to prevent the propagation of the virus, as Dr. Daher explains in an article[11].

The regime’s way of “securing” the population