AMMAN – When Um Farah (a pseudonym) caught COVID-19 and started developing breathing problems, she did not know where to turn for help. Around her village in the countryside of Syria’s central province of Homs, there were no functioning public hospitals; all were destroyed or closed during the conflict.
To alleviate the symptoms, Um Farah’s family started looking for an oxygen tank, but the closest health center told them none was available.
Um Farah’s sister, a Syrian refugee living in Amman, inquired daily about her sister’s health. The family, she told Syria Direct, would not have managed to access oxygen if not for a relative working in the Syrian government. “They looked everywhere without success and ended up buying it from people affiliated with the regime.”
Like Um Farah, many Syrians infected with COVID-19 struggle to find treatment to alleviate their symptoms amid a severe shortage of medical equipment. As a result, they have no choice but to turn towards the parallel market.
Shortage of medical equipment
There are no reliable figures on infection rates in regime-held areas. The data provided by the Syrian Ministry of Health (MoH) to the World Health Organization (WHO) adds up to less than 17,000 cases across regime-held areas, a severely underestimated figure compared to those made available by other countries in the region.
These blatantly unrealistic figures aim to contain public awareness of the severity of the pandemic, which Syria is not prepared to meet.
According to the MoH data, Syria has 21 treatment (isolation) hospitals containing 934 treatment (isolation) beds, 210 intensive care unit (ICU) beds, and 185 ventilators. By comparison and for a much smaller population, neighboring Jordan has over 4,000 treatment (isolation) beds, 879 ICU beds and over 900 ventilators available.
“The pandemic continues to create an acute shortage of essential supplies, including diagnostics and case management equipment,” the WHO Syria office told Syria Direct. To date, WHO supplied 73 oxygen concentrators, 51 ventilators and two oxygen generating stations to health partners in Syria, but highlighted “limited means to access international testing supplies and clinical care equipment.”
Although the Syrian medical sector is exempted from EU and American sanctions, including the most recent Caesar Act, it suffered an indirect blow as multinational companies became wary of involvement in Syria. Access to medical supplies decreased due to restrictions on financial transactions with Syria and other logistical constraints, including international shipping companies avoiding the Syrian market.
Widespread medicine shortages were reported in Damascus in the spring of 2020. The shortages were allegedly linked to disagreements between the MoH and pharmaceutical companies on the price of medicine, as pharmacies struggled to import medicine after the Syrian pound collapse. To ease the crisis, the government agreed to increase the selling price of 1,400 medicines and set a preferential exchange rate for medical imports.
In addition, around fifteen new medical supplies import companies have been established since the start of the pandemic, mostly by low-profile businessmen. The fact that many were created simultaneously, in June and July 2020, could indicate a coordinated push by the regime to feed the Syrian medical market.
Uneven access to healthcare
Many Syrians don’t seem to benefit from an increased supply of medical equipment, simply because they have no access to health infrastructure.
Prior to the war, Syria had a well-functioning health sector, despite imbalances in medical coverage between rural and urban areas. But ten years of conflict have severely undermined it and aggravated pre-existing disparities.
By 2020, nearly 70% of Syrian healthcare workers had left due to the conflict. Around half of Syrian hospitals have been damaged or destroyed, most as a result of targeted military attacks by Russia and the Syrian regime.
Furthermore, according to a report by Physicians for Human Rights (PHR) organization, “the Syrian government has done little to rebuild areas formerly under opposition control or to replace the essential health services that were provided by the humanitarian organizations that were forced to withdraw following the government takeover of the area.”
“The shortage in medical supplies is related to neglect from the Syrian government’s side,” Dr. Houssam al-Nahhas, a researcher at PHR, told Syria Direct. Thus, residents of the southern Daraa province reported a lack of critical medical supplies such as ventilators, compared to the relative availability of ventilation machines in areas of the country considered loyal to the Syrian government.
Meanwhile, WHO data shows that isolation hospitals are concentrated in Damascus (four hospitals), the provinces of Aleppo and Daraa (three hospitals each), and Reef Dimashq province (two hospitals), with only one hospital in the urban core of other provinces. Suwayda province is entirely devoid of any ICU bed or ventilator, while there are nearly 40 in Damascus.
An oxygen crisis
According to the WHO, Syria has several oxygen-generating facilities and an estimated 60 oxygen generating stations in public health facilities, the capacity of which ranges between 6 and 20 m3/hr. Accordingly, “NGOs and health partners can purchase oxygen cylinders and refill them locally,” according to the WHO Syria office, and WHO provides public hospitals with oxygen tanks, concentrators and oxygen stations based on their needs.
However, many live far from any hospital, are turned away due to lack of space, or consider the trip to be too dangerous due to concerns that include being arrested at checkpoints. “Those with enough resources prefer to go through the black market or the private sector, considered as safer options COVID-wise,” al-Nahhas added.
While essential medical supplies, including oxygen tanks, concentrators and oximeters, can be hard to access in health centers and pharmacies, some are sold openly on various Facebook groups and Telegram channels. “People reported paying out of pocket to get medical supplies required for COVID-19 treatment,” al-Nahhas said.
“This represents a heavy financial burden,” Sara Kayyali, a researcher at Human Rights Watch, told Syria Direct. Based on interviews she conducted with residents and nurses, oxygen tanks can be bought from private suppliers for a price of around $500 per tank and $12,000 for a ventilator. The normal price of these items should be around $100 for an oxygen tank and $800 for a ventilator.
Part of this equipment is allegedly smuggled into Syria from Lebanon, which also experiences severe strain on its public health sector. Many Lebanese have resorted to buying medical equipment for personal use, and some could end up in Syria.
“I know someone who bought Lebanese oxygen tanks for their relatives,” Suhaib al-Ghazi, a researcher and open-source analyst, told Syria Direct. The tank was bought in Beirut and smuggled by car to Aleppo. For al-Ghazi, the market is likely to be run “by people who are somehow affiliated with local militias. It’s just another scheme to make a profit.”
A part of the parallel market is built on pre-existing smuggling networks and individual efforts to send help back home. “Money coming from abroad is the main source of support for those seeking such expensive services,” al-Nahhas said.
Another potential source of supply is the diversion of equipment from aid shipments and the health sector within Syria. In a context of widespread corruption, “some people have seen and found aid ventilators sold on the black market,” Kayyali said.
In addition, “there were reports about the Syrian government selling the COVID testing kits donated by other countries,” al-Nahhas added. Local observers also reported people having to pay bribes or use personal connections to get admitted into hospitals.
However, a senior INGO worker with experience in the medical sector told Syria Direct that while the diversion of public equipment and aid is a possibility, “it is unlikely to be a systemic practice, due to the fact that the regime faces a real scarcity of medical equipment.”
The WHO Syria said it has its own focal points in all Syrian provinces “who follow up on the distribution and the installation of delivered equipment. Each [piece of] equipment has its own serial number and is to be tracked as needed.”
Despite this, many see the parallel market and official institutions as somehow interlinked. “At the health center, they tell you that they have no oxygen, but later someone contacts you to sell you some through the back door,” explained Um Farah’s sister. “Of course, we cannot know where the oxygen comes from, and we do not ask, but I believe these things are connected.”
Syrians in the regime-held areas already struggle to access bread, fuel and essential commodities, which are diverted from subsidized stocks and sold on the black market at prohibitive prices. The pandemic has further exacerbated their distrust of official institutions mined by corruption. The COVID-19 response is just another facet of this increasingly exploitative economic ecosystem.