The novel coronavirus (COVID-19) pandemic has resulted in over 4.6 million confirmed cases and more than 319,000 total deaths worldwide. Despite the severe pressure COVID-19 has placed on even the most capable health systems, the virus is expected to have a disproportionate impact on health systems in low- and middle-income contexts, especially those impacted by conflict. The Middle Eastern and North Africa (MENA) region, which is host to the most concentrated number of graded emergencies and protracted conflicts, is particularly vulnerable to the social, economic, and political impacts of a COVID-19 epidemic, both within and across individual country borders. Countries with Grade 3 emergencies, such as Syria (58 confirmed cases of COVID-19), and Yemen (130 confirmed cases of COVID-19), have been slow to report cases and related deaths (3 in Syria, 20 in Yemen) due to ongoing uncertainty imposed by authoritarian leaders, the presence of armed groups, ongoing conflict, and mass displacement.
Relative to other countries in the region, Syria is exceptionally unprepared to manage the potential of a COVID-19 outbreak. Even before the beginning of the conflict in 2011, Syria’s healthcare infrastructure, including the national health system’s capacity to prepare and respond to outbreaks, was considered below average in comparison to other MENA countries. Nine years of conflict have devastated the health system, particularly in areas outside of government control. The ongoing targeting of health facilities and personnel bears an existential impact on the Syrian health workforce. Physicians for Human Rights has recorded 536 attacks by the Syrian government and its allies on nearly 350 separate health facilities since 2011, as well as the targeting and killing of 830 medical professionals inside Syria. Among the 6.1 million Syrians displaced since the start of the conflict, more than 70 percent of the health workforce has reportedly fled the country, resulting in an acute shortage of health professionals across Syria, and particularly, medical specialists with the capacity to respond to a potential COVID-19 outbreak. Even before the conflict, critical health resources, such as ventilators, intensive care unit (ICU) beds, and advanced personal protective equipment (PPE), were scarce inside Syria. With existing COVID-19-specific resources, researchers at the London School of Economics estimate that a maximum number 6,500 of COVID-19 cases could be adequately treated across Syria given existing resources; meaning, 0.04 percent of the national population. However, due to the fragmented nature of the Syrian health system, the capacity to respond outbreak differs significantly across Syria’s provinces including government-controlled areas to the northwest and the northeast parts of the country, the latter of which have been most impacted by the conflict in recent years.
A total of 58 cases have been confirmed by the Syrian Ministry of Health in government-controlled parts of Syria, which include three deaths and 29 recovered patients since the first case was reported on March 22, 2020. The Syrian government has attempted to enforce a 12-hour curfew (now reduced by one hour for Ramadan), limit land border crossings, and impose a lockdown on public universities and facilities; however, there have been increased reports of pulmonary infections and pneumonia-related deaths in patients over 60 years old across the country. In addition, the Syrian Ministry of Health is working with the WHO in Damascus to respond to COVID-19 cases and have reported a total of 3,325 who have been quarantined with COVID-19-like symptoms, of which 771 remain in isolation. There is speculation by Syrian public health specialists that the government is not being fully transparent with the local population about the scale of the outbreak in Syria, and that the movement of Iran-backed militias and pilgrims into Syria may have spread the crisis beyond what the government would confess. In early March, the Syrian Health Minister denied the presence of any COVID-19 cases in Syria, in the same interview where he likened civilians in opposition-held Syria to bacteria. While Syrian President Bashar Al-Assad emphasized the impact of COVID-19 inside the country’s borders, the seemingly low number of reported positive cases and otherwise hushed response from the Syrian government is reminiscent of previous reactions to disease outbreaks in Syria, such as the devastating re-emergence of poliomyelitis, an infectious disease which can cause permanent paralysis, in northeast Syria in 2013, which led to 74 confirmed cases by the time it was stopped in 2017. The Syrian Ministry of Health in Damascus continued to deny the existence of polio in the northeast and was reported to have limited aid and supplies from reaching humanitarian actors in these areas working towards responding to the disease, until evidence collected by humanitarian organizations in non-government controlled areas was published with support from the Center for Disease Control and Prevention (CDC). In the context of COVID-19, this example suggests the urgency of evidence-based modeling and high-quality forecasting to reflect accurate spread and transmission of COVID-19 across Syria.
In areas outside of government control, there have been three reported cases, and one subsequent fatality, of COVID-19 in Qamishli National Hospital northeast Syria. A two-week delay in reporting and confirmation of a positive case of COVID-19 in northeast Syria led to responses from the Kurdish-led autonomous administration and other local authorities in northeast Syria, blaming WHO, the Syrian government, and the international community at large for delays in reporting. The case, which was identified when a 53-year old man from Al-Hasakeh City was admitted to the hospital on March 27, had tested positive despite having no travel history or contact with other confirmed cases, suggesting imminent spread and transmission in this area. The two other cases identified on April 30 are reported to be family members of the previously identified case, confirmed by the Autonomous Administration of North and East Syria. Surveillance efforts have been implemented by UN OCHA and WHO in Syria to monitor future cases and mitigate potential spread, while international and local NGOs are coordinating with local health authorities to prepare facilities and ensure supplies for medical staff responding to the potential outbreak.
In northwest Syria, there are no confirmed cases of COVID-19 despite ongoing testing and expansion of surveillance efforts. With a population of over 4 million (51 percent children and 25 percent women) across Idlib and northern Aleppo, the scale of humanitarian needs are unprecedented, particularly in light of the COVID-19 pandemic. Since December 2019, over 1 million civilians have been displaced from small towns and sub-districts throughout northwest Syria farther north towards the Turkish border following an uptick in military attacks from the Syrian government and its allies. These hostilities have also resulted in the destruction of nearly 70 health facilities since April 2019, resulting in limited access to healthcare for displaced families. Cross-border hubs led by the WHO in Gaziantep and Amman are mobilizing resources to ramp up preparedness and response to northwest and southern Syria, despite stricter limitations in cross-border access due to COVID-19 in addition to the partial renewal of UN Resolution 2449, which allowed only two of the four border crossings in Turkey to remain open. While humanitarian supplies are allowed to cross through these areas, approvals from Turkey and Syrian local councils must be secured, leading to delays in procuring and delivering essential aid and supplies, including PPE, ventilators, and testing kits.
There is well-founded concern among humanitarian actors and local authorities in areas outside of government control that COVID-19 could spread rapidly in the crowded and unsanitary conditions within the many internally-displaced camps (IDP) and informal settlements across the northwest (706 sites hosting 1,150,000 IDPs), the northeast, (Al-Hol camp, host to 65,000 IDPs) and in the south (Rukban camp, which hosts over 12,000 IDPs). In the meantime, local authorities, in collaboration with WHO and other agencies, are ramping up their support to local organizations, civil society organizations, and international non-governmental organizations providing health services in these areas. For example, curfew restrictions have been imposed in northeast parts of the country, including lockdown of Al-Hasakeh, where the positive COVID-19 cases have been identified. The WHO Turkey hub in Gaziantep has set up a COVID-19 task force, composed of humanitarian partners operating in the northwest of Syria. Among these partners are health professionals and organizations who have weathered attacks on hospitals, including multiple chemical attacks, which have provided them with the experience in triage, PPE, and crisis mitigation skills required to address a potential viral outbreak.
As public health stakeholders continue to work in silos across the country to mitigate the potential impact of a widespread COVID-19 outbreak inside Syria, the international community should take heed of the urgent gaps in funding and resources in each of the health systems across Syria, as well as the limitations in cross-border and cross-line access to hard-to reach areas, particularly the northeast and southern parts of the country. This includes the impact of the war-time economy and international economic conditions on Syrian civilians, who are tempted to return to work despite social distancing measures and stay-at-home orders imposed across the country. Therefore, preparedness and response efforts should be realistic and sensitive to the current state of affairs and local conditions in each of the geographic domains.
The short- and long-term implications of a COVID-19 epidemic across Syria’s divided geographical areas and political factions are stark. A lack of transparency and urgent cooperation from the Syrian government with other governing actors across the country, the potential of ongoing hostilities and protracted displacement, compounded by an ill-equipped health system with reduced human resources for health and global shortages in critical health resources necessary for COVID-19 response, will have a lasting impact on the national and regional economy, and most importantly, on the global fight against COVID-19.
Editor’s note: Figures were updated on May 19, 2020 to reflect the increased number of confirmed cases and deaths since publication.