It's been almost a decade into a devastating war that displaced two thirds of the population, hundreds of thousands of whom barely survive in makeshift, chaotic camps. Syrians had barely come to terms with the latest regime attacks on the north-western Idlib province, which made over 60 health facilities inoperable and displaced over 1 million civilians. News of a looming medical catastrophe so huge it collapses the most advanced medical systems in the world, is still barely comprehensible to most. So far people’s reactions have shifted from negating the severity of the pandemic, to distrust in official regime numbers, to cynicism over what form of death there is left for them to survive, to the plain nihilism of not trying to save themselves anymore.
Diverse medical realities on the ground
After over 9 years of conflict, the country is currently split into three control areas, and such fragmentation also impacts management of the coronavirus crisis. Two thirds of the country has been returned to regime control with Russian and Iranian support since 2015. The other two parts are the northeast under Kurdish-led, US-backed, Syrian Democratic forces, known as the Autonomous Administration areas, and the rebel-led northwest, under no real central administration, but with a clear upper hand for Turkey-backed forces and institutions. The medical infrastructure and preparedness also differ from one zone to the next, with much reliance on local and international NGOs and aid in northern areas. However, those differences remain marginal, compared to the scale of response needed to confront such a tsunami.
A recent report released by LSE has estimated the country’s overall capacity for treating COVID-19 patients at around 6,500 cases, in a country with a population estimate of over 17 million. According to their calculations, there are only 325 available ICU beds with ventilators in the whole of Syria. They are disproportionately distributed, with the highest concentration in the hands of the regime (ca. 200 in the capital and the coast alone), while the city of Dier Ezzour, for instance, has none, despite being swamped with Iranian militias, believed to be the main source of virus entry into Syria.
China and Russia lead an international call to lift sanctions against the regime under the pretext of prioritising health over politics, but the regime still refuses to allow international monitors into its detention centres, let alone release the tens of thousands of political prisoners believed to be crowded together in inhumane conditions, potentially turning into gas-chamber situations any minute.
Regime areas: a healthcare system with depleted resources
After about a month of jokes about the brazen regime denial of COVID-19 cases, by mid-March, confirmed cases in Pakistan and Iraq officially reported to have arrived there from Syria forced the regime to admit the presence of only 1 case. It then immediately moved on to measures like shutting down schools and universities, imposing a night curfew, and halting reserve drafting. Some travelers coming in from Iran were put into inadequate quarantine facilities as the last flights arrived before airports were closed. Land borders currently only allow emergency cases, military and essential commercial goods to pass, in addition to aid. The regime has since admitted the existence of 5 more cases, and 2 deaths only. Leaks form hospital staff about a sudden rise in fatal "asthma and respiratory disease" cases sweep through the country. No reporting has yet been able to estimate what the real number of cases may be, and not many care to investigate. The war, destruction, economic collapse, sanctions, skyrocketing levels of corruption and security chaos left medical services at less than half their original capacity, even in the least damaged areas.
Huda M., a 45-year-old school teacher in Damascus has a 19-year-old daughter with a heart condition, due to repeated shocks during the war: “We're staying at home, only going out with masks on, cleaning and disinfecting all day. I've bought regular flu medication, it’s not like there is a cure for it yet anyway. We know we don’t stand a chance at a turn in the hospitals after all the military members, the corrupt and influential, the rich that bribe staff… it’s best to die with decency at home”.
Huda’s middle-class income and small household allows her the “luxury” of social distancing in a clean home, as prices for detergents and face masks have rocketed out of regulation control to over tenfold their original price. Almost all other basic goods have had increases, although smaller, in prices, and government-subsidised goods are only a cause of worry as people crowd their outlets to get their share. Over 80% of Syrians today live below the poverty line, as the currency value dropped from 45 Syrian pounds per US Dollar in 2011, to around 1150 according to the latest estimates.
The Northeast in desperate need of medical resources
Under the somewhat organised Autonomous Administration, this area has the weakest medical resources. It has less than 25 ICU ventilators for an estimated population of over 4 million, 600,000 of whom are displaced and about 100,000 living in rough and makeshift camps. A recent cut in water supply from the Turkish side took much local and foreign pressure to get desperately needed water back to those camps, some of which hold the families of ISIS fighters. A recent jailbreak in the central prison of Al Hasakeh by the imprisoned ISIS members there went almost entirely without any news coverage, as everyone has bigger worries now.
The area’s first defence line so far has been the organisation of its administration that enjoys more local credibility than what the regime has in its areas. Schools and universities were closed, the annual New Roz festivity of 21 March was cancelled, borders were shut and a lockdown was announced even before any cases were reported.
Lack of test kits, medical staff and facilities remains a huge concern for the population, which doubts the area’s ability to detect any cases. Samples are being sent to the northwest for testing, despite political alliances with the regime reportedly being better and the WHO overtly prioritising government-controlled areas over rebel-held territories in aid supply.
Prices of basic goods, except for bread, have also started to rise. There are doubts as to the ability of the local administration to enforce a long quarantine with most people depending on the daily odd job or money transfers from family members oversees they can no longer receive with borders closed and international sanctions complicating bank transfers.
Abu Abdallah, a 34-year-old truck driver from the city of Raqqa with a chronic digestive illness told us: “People are more scared for their livelihoods. They are starting to display symptoms of bankruptcy, not corona symptoms. This is scary. In war and relative chaos…"
Will the war-ravaged Northwest survive coronavirus?
Most of the province of Idlib and some parts of rural Aleppo and Lattakia remain outside of regime control, but not really under any single organised rule either. This makes enforcing any quarantine measures particularly complicated. The population estimates are around 4 million, about 1 million of whom live in poorly constructed camps, or even caves and olive groves. Access to water and sanitation and health services are beyond modest for this population. Local medical sources say there are only about 240 ICU beds and 100 ventilators available in the entire area. The WHO has so far sent only 600 of the 2,000 testing kits it had planned for this zone, and local doctors confirm there have not yet been any cases detected.
This comes as somewhat of a relief to locals, who tend to trust those sources. But they know this can only be controlled for so long. Civil society organisations, very active in all aspects of life in the area, have been on full force to spread awareness of the importance of social distancing and hand washing, knowing how hard it is for a displaced family of 15 people living in one tent to stay home. The most difficult challenge they encounter has been a tendency for some to think that after surviving years of regime shelling, chemical attacks, hunger sieges and displacement, a flu virus is not going to kill them. This does not come from ignorance, argue some of those workers, but from a mental state that simply needs the denial. Cecelya Taweel, a local activist in rural Idlib, explained through Facebook a reaction she faced last week: “We were distributing brochures in the shops in a village near Afrin, when a man came up to us and tore them up, saying we don’t have corona here”. On Tuesday, she posted a statement saying the village mosque was going to announce quarantine, requiring everyone to go home.
Despite the grimness of the overall reality, people still console themselves with the hope that the virus will be less contagious as it warms up in spring, or that the youthfulness of the population will minimise casualties.