AMMAN — “It’s a ticking time bomb; we’re maybe a month behind Damascus in terms of the COVID outbreak.” This is how a western aid worker involved in the COVID-19 response described the situation in northeastern Syria, comparing it to the government-held territories, which could have, according to some sources, up to two million cases. 

Since August 1, the number of COVID-19 cases has exploded in northeast Syria, jumping from 28 to 556 cases, leaving health workers scrambling to try to contain the growth of the disease. Worryingly, the first case in the densely populated, under-resourced al-Hol camp was also recorded late Saturday, August 29. 

The spike in caseload, however, likely still severely understates the true spread of COVID-19 in the area.

Northeast Syria has the lowest testing rate of any other part of Syria—404 tests per million people as of August 25—and the highest rate of positive results relative to tests performed. Around 30 percent of tests conducted thus far have been positive, as per an update by the NES COVID Forum on August 27. According to the WHO, a positive ratio greater than five percent indicates severe under-testing in a population. 

In the city of Qamishli, for example, only 60 to 70 tests can be performed a day because there is only one lab team capable of performing them, the aid worker told Syria Direct, speaking under the condition of anonymity because they are not authorized to speak to media. 

Still, a lack of testing might be beside the point in northeast Syria as contact tracing is proving to be difficult, due to the “sheer number of contacts” and low number of contact tracing teams, according to the NES COVID Forum update. 

In addition, precautionary measures are not being applied uniformly throughout northeast Syria, nor is much of its population adhering to these measures, further exacerbating the spread of COVID-19. 

“We have to assume that we have active community transmission across all areas of northeast Syria now,” the aid worker said.

“In many of these areas, nothing is being done to contain the outbreak at this stage.”

Governance structure and lack of capacity undermine COVID-19 response

The Autonomous Administration of North and East Syria (AA) prides itself on its decentralized form of governance—described as democratic confederalism—wherein governance is devolved to local provincial and city councils. However, it might be this very form of governing that is most ill-suited to combatting COVID-19, which requires a strong administrative response to enforce public health measures. 

“Since July, the authority for making [public health] decisions has been decentralized to the local civil and municipal authorities,” the aid worker said. The result is an uneven administrative response to COVID-19, where “you have a relatively stringent lockdown” in Hasakah province, but in somewhere like Raqqa province, there is no “lockdown for all intents and purposes.” 

Lack of coordination between the governorates and local councils in northeast Syria has also hindered the work of public health officials. Specifically, the Rapid Response Teams that are tasked with collecting COVID-19 samples and conducting contact-tracing across northeast Syria have been prevented from accessing certain areas of the AA-governed territory. 

Still, despite movement restrictions in place in Hasakah province, there is still movement into the province from regime-held territory, where the COVID-19 situation is most dangerous. The Qamishli airport is still under regime control and has continued to operate flights to and from Damascus throughout the COVID-19 crisis, creating another method of contagion. 

Pro-AA media outlet, NorthPress, alleged that around 3,500 passengers fly into Qamishli from Damascus each week. 

A picture alleging to show civilians transported in a Russian cargo plane from Damascus to Qamishli, 30/08/2020 (Mohamed Herdam

In addition to governance issues, public health officials who spoke to Syria Direct pointed to a fundamental lack of medical capacity as undermining the response to the COVID-19 crisis. 

Even before the Syrian revolution and the ensuing war in 2011, northeast Syria had the lowest medical capacity in the country. After nine years of war, the area’s capacity has only further degraded; there were only 22 Intensive Care Unit (ICU) beds available for four million people as of late March, according to a medical assessment by a Syrian researcher at the London School of Economics (LSE). 

Since the study has been published, the physical capacity of the northeast to accommodate COVID-19 patients has grown, with new facilities having been built. However, the deficit in human capacity is perhaps just as important for the area’s COVID-19 response. There are not enough doctors for the area, and in addition, many of these doctors and health professionals do not have the proper training in either diagnostic practices or precautionary health measures. 

A large number of the current COVID-19 cases in the northeast are among healthcare professionals themselves. This is in part due to improper use of Personal Protective Equipment (PPE) and faulty triage procedures for patients who are expressing symptoms similar to those of COVID-19, according to the aid worker. 

The high infection rate becomes an even greater problem as doctors in the northeast often work in more than one medical facility at once, sometimes even up to four at a time. If infected, these doctors could be transmitting COVID-19 to multiple healthcare facilities and spreading the disease to different clusters of healthcare workers. 

As a result of infections among healthcare workers, eight NGO-run medical facilities were closed and another 15 were operating at partial capacity, according to the August 27 NES COVID Forum report.

Further, as of Monday, August 27, only 27 of the then total caseload of 478 COVID-19 cases had been put into isolation facilities or hospitals, risking further contagion. Instead of isolating patients, doctors have been testing them, and then sending them home to wait for their results.

Compounding all of these factors is the shortage of medical supplies in the area. Northeast Syria, unlike the opposition-held northwest or regime-held territories, does not have a border crossing accessible to the UN. 

Al-Yarubiyah crossing on the Syrian-Iraqi border previously served as the conduit for UN aid to the area, but the UN Security Council resolution authorizing the use of the border crossing expired in January 2020. Now, all aid must be delivered cross-line from regime-held territory, a difficult task to coordinate. 

Further, northeast Syria has suffered from a serious water shortage for the past month, due to Turkish-backed forces shutting off the Allouk water treatment station, which is the main source of potable water for the area. 

Shahba left to fend for itself

One of the emerging COVID-19 clusters in AA-controlled territory is in the Shahba area, in Aleppo province. The area is geographically separated from the rest of the political authority by Afrin, which has been under the control of Turkish-backed opposition fighters since 2018. 

At the time of publishing, Shahba had 44 confirmed cases, though a member of the Kurdish Red Crescent (KRC) who works in the area told Syria Direct that they expect the true number of cases to be much higher. According to the KRC worker, many residents are presenting symptoms of the disease, but are scared to get tested as they are afraid of the results. 

Shahba has a population of 150,000 people, most of whom are Internally Displaced People (IDPs) who fled Afrin following Turkey’s Operation Olive Branch. The area is serviced by just one hospital and suffers from shortages in PPE and diagnostic equipment, according to the KRC member.

The hospital only has six ICU beds and three operating rooms, an aid worker involved with the COVID-19 response in the area told Syria Direct. A medical facility was also recently established in the village of Hassajk, which has 26 beds and is specifically equipped to treat COVID-19 patients. 

In addition, the KRC maintains six emergency field clinics across the area; however, these medical points are only staffed by nurses and suffer from shortages in equipment and generic drugs. 

The KRC had previously issued a statement this month appealing for help from the WHO, International Red Cross and other international organizations. However, to reach Shahba, organizations would have to pass through Afrin, which is controlled by armed groups and is considered extremely unstable.

As a result of the degraded security conditions, the UN has been unable to send any staff or supplies to Shahba. As it stands there is only on NGO active in the area, providing health care through mobile clinics and community health workers.

Public health measures have been taken, such as the banning of large gatherings and the prohibition of movement between sub-districts. Previously, two villages—Umm Hosh and Ahras—were placed under quarantine after COVID-19 cases were discovered there. Further, information about how to prevent the spread of COVID-19 was disseminated in Arabic and Kurdish via brochures and loudspeakers. 

Still, it is unclear how well residents can adhere to precautionary measures due to shortages in basic supplies and the poor living conditions of the IDP camps there. 

“As if the suffering from displacement wasn’t enough, now it has only increased due to the fear and panic from the virus,” the KRC worker said.