AMMAN — In two months, the number of COVID-19 cases in the opposition-held northwest Syria region increased fifty-fold, from 138 confirmed cases on September 8 to 7,500 on November 5. These include 2,729 recoveries and 42 deaths. The figures are probably higher, given the limited testing capacities, now at around 500 tests per day, according to the latest situation report on northwest Syria from the Office for the Coordination of Humanitarian Affairs (OCHA). Over 13% of the cases have been recorded among medical workers and 7.5% among other health sector workers, a worrisome indicator of growing strain in the health sector in an area that hosts around four million persons, half of them Internally Displaced Persons (IDPs). 

Northwest Syria is still underserved

According to OCHA, northwest Syria has five testing labs, 34 community-based treatment centers and nine hospitals with 645 available beds, 142 intensive care unit (ICU) beds and 155 ventilators. Six hospitals are dedicated to COVID-19 patients in Idlib, Dr. Yahya Nami from the Health Directorate in Idlib, told Syria Direct. Further, in addition to one testing lab in the city of Idlib that contains two polymerase chain reaction (PCR) machines, two other testing labs with PCR machines became operational in October, according to OCHA, in the cities of Jarablus and Afrin in the northern countryside of Aleppo province. 

Today, “suspected cases are reported by doctors in health facilities and then transferred through the referral system to community isolation centers, where samples are collected, and a PCR analysis is performed to determine the result,” Dr. Mohamed Salem of the Early Warning and Response Program (EWARN) at the Assistance Coordination Unit, told Syria Direct

However, “the test is not the most important component, as the medical procedures following the positive result are more important than the result in itself,” Salem warned, stressing the urgent need for more support “in the food and water sector, intensive care, oxygen generation plants, and general infrastructure.” 

Since the beginning of the pandemic, northwest Syria remains medically underserved. On October 24, the World Health Organization (WHO) announced the delivery of an “8.8-ton shipment [including] medical kits and medicines for almost 2,000 beneficiaries and enough personal protective equipment to protect more than 4,000 health care workers.” The supplies were handed over to the health authorities in Damascus, but it is unclear how much will reach northwest Syria. Syria Direct tried to communicate with the WHO liaison office but did not receive a response.

A health crisis compounded by a humanitarian one 

COVID-19 is an additional burden in northwest Syria’s dire humanitarian situation. Water, sanitation and hygiene are the pillars of COVID-19 prevention, but northwest Syria already lacked these services prior to the pandemic. In his briefing to the Security Council on the humanitarian situation in Syria on October 27, 2020, Mark Lowcock, the UN Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, stressed that “the rapid spread of the virus [in Al-Bab area in Aleppo province, where 30% of cases have been recorded] is not very surprising.” He added that “water shortages have affected 185,000 people in the area since 2017, when the supply from the Ain al-Bayda pumping station stopped. Since then, Al-Bab [is] one of the top four sub-districts reporting water-borne diseases.” 

In parallel to COVID-19, NGOs “are also focused on responding to a dramatic rise in visceral leishmaniasis and Multi-Drug Resistant (MDR) tuberculosis cases in northwest Syria,” according to OCHA’s October 20 situation report. 

Housing in displacement sites is densely distributed and uninsulated. “The main cause of the increase in cases comes from (...) the high density of population in the camps, and crowded living conditions there leading to gatherings, such as communal bathrooms,” Abdulrahman Hallaq, Director of Sham Isolation Hospital in Idlib, told Syria Direct. “People in the camps often cannot isolate themselves in their tents,” he added.

The cost of isolation

Isolation, which means not going to work, is not an option for many in northeast Syria. “You sometimes see a COVID patient in the street, opening his shop, telling you he does not want to stay ten days in the house because he wants to live,” Dr. Salah Al-Din Al-Saleh, director of the Agriculture Hospital in Idlib, told Syria Direct. “He cannot afford to stop working.” Likewise, as noted by Salem, “preventing gatherings and markets, imposing a curfew and increasing the use of disinfectants and hygiene materials is an economic burden for people living under war and bombing.”

Women are particularly impacted because they are more likely to work in the informal sector. According to Care International’s rapid gender analysis on the impact of COVID-19 in the Middle East, women “are impacted [by COVID-19 through] losses in the informal labor market, elevated levels of violence, and increased burdens of caregiving for out-of-school children, sick and elderly family members.” A study published by Friedrich Ebert Foundation in July 2020 found that “as [family members] fall ill, women are more likely to provide care for them, putting themselves at higher risk of exposure to the virus.” In the long run, the study warned about “additional risks that the lack of education may also cause an increase in child labor and forced marriages as people struggle financially.”

A press release issued by organizations operating in northwest Syria and published on the Idlib Health Directorate Facebook page estimates that "71% of families are unable to cover their living needs and a third of families saw their income affected by COVID-19". 

Currently, “there is pressure on all hospitals and the situation is not under control,” said Hallaq, “yet we are aware that this is not the worst situation. We expect to reach an explosion in the number of cases in November due to the ongoing contamination of people.”