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COVID-19: A Ticking Time Bomb in Northern Syria’s Refugee Camps

Ahmad El-Haj Bakri

COVID-19: A Ticking Time Bomb in Northern Syria and its Refugee Camps (Promo)
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"There is no place for social distancing here. We are 40 people, and have lived in eight tents since 2015", says 62-year-old Maryam Sheikh Omar.

"There is no place for social distancing here. We are 40 people, and have lived in eight tents since 2015," says 62-year-old Maryam Sheikh Omar.

Maryam has 15 boys, one girl, and 18 grandchildren. She has lived with her family in ‘Ahl al Qur'an’ camp in the western countryside of Idlib on the Syrian-Turkish border, ever since she was forced to flee her village.

On a video call, Maryam narrates the details of her daily routine that has remained unchanged in the times of COVID-19.

She wakes up everyday at dawn before waking the rest of her family, to start preparing for work. Collectively, the family starts preparing food in large quantities sufficient for everyone.

Around 1000 refugees live in the ‘Ahl al Qur’an’ camp, and after the recent wave of displacement, the number has increased, according to the camp’s director, Muhammad Sheikh Ismail.

"Here, social distancing and preventive measures recommended by the World Health Organization and other associations are not possible," he said. "There are no health or service facilities in the camp, and the number of tents is simply not sufficient for the number of people we have, therefore, social distancing and self-isolation is not possible.”

"In each tent (two meters wide and three meters long), there are at least five people who share food and drink, while each section (consisting of 40 tents) has a total of six toilets; three for men and three for women,” Ismail said.

Despite the ongoing threat of the virus, residents felt reassured due to the blockade imposed by the Syrian government, and the Turkish government’s closure of three land crossings: ‘Bab al-Hawa’, ‘Bab Al-Salamah’, and ‘Jarablos’. In addition, the area had no airports or ports (through which infected visitors might enter).

Airports and other ports have also been relatively empty since the area’s first recorded case.

However, the severity of the situation evolved after July 9 when the first cases were recorded. one of the victims was a working Syrian doctor at ‘Bab AL-Hawa’ hospital, who had recently returned from Turkey.

A modelling study carried out by the Med Archive Health Foundation, in cooperation with health directorates in northern Syria, projected that the potential number of coronavirus cases will be high and widespread if necessary precautions were not observed.

The study indicated that infections may reach up to 240000 (about 20% of the internally displaced population in Northern Syria), of which 36000 would develop severe infections, 12000 would be critically ill, and 14328 could contract the infection that would be fatal.

These areas mostly rely on preventive measures implemented and funded by civil society and non governmental organizations that have limited capabilities and resources.

“From late April to September we sterilized 115 camps spread between Al-Zouf to the village of Badama, including the ‘Ahl al Qur’an’ camp. We also sterilized approximately 22 villages in the western countryside of Idlib, and targeted areas with high population densities,” The Director of Lattakia region in the Syrian Civil Defense, Muhammad Haji Asaad said.

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[Until September], we only had one laboratory in Idlib equipped with tools for analyzing samples. It was proposed to equip two new laboratories; one in the city of Jarablus [northeast of Aleppo] and the second in the city of Afrin [north of Aleppo]. Some of the equipment has arrived, albeit late, and included 6,0000 analysis kits and tests, which will be activated very soon.

Dr. Mahmoud al-Hariri, the director of the health information unit in northern Syria (including Hama, Aleppo, the Sahel and Idlib) who works directly with WHO, told ARIJ that, "[Until September], we only had one laboratory in Idlib equipped for analysing samples. It was proposed to equip two new laboratories; one in the city of Jarablus [northeast of Aleppo] and the second in the city of Afrin [north of Aleppo]. Some o f the equipment has arrived, albeit late, and included 6000 analysis kits and tests, which will be activated very soon.”

Dr. Muhammad Al-Salem, director of the vaccine program and member of the Early Warning and Epidemic Response Network, says that "1390 tests were conducted for suspected cases by the end of June, all of which were negative.”

According to Al-Salem, the Idlib lab analyses results are those from various areas and is not restricted to the governorate alone. Samples were collected from Deir Ezzor, Raqqa, Aleppo and Hasaka were analysed in Idlib, he told ARIJ.

The Assistance Coordination Unit (ACU) runs the only laboratory in the opposition-controlled areas of northern Syria. According to Al-Salem, in the event of a positive result, a second swab is taken to a Turkish lab for confirmation. This takes usually 24 hours. Hospitals in the north and north eastern parts of Aleppo samples collected there are sent to Turkey for analysis.

Just two days after the first COVID-19 case was recorded in opposition-controlled areas, on July 11, the Ministry of Health of Syria’s interim government announced that the number of cases had risen to three – two of which belonged to doctors working in the A’zaz City Hospital who had recently returned from Turkey.

As of 23 July, the number of confirmed cases had risen to 22 out of 3111 tested, according to Dr M. Ram Al-Sheikh.

On September 5, the Early Warning Network announced an additional 14 recorded cases — the highest since the pandemic reached the north, bringing the total number of cases to 112.

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An Exhausted Medical Sector

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Currently, Northern Syria does not have a unified health system, and only a few limited health institutions are operating at maximum capacity to fulfil the needs of more than 4 million people in an unstable and unprepared area,

“Currently, Northern Syria does not have an integrated health system, and only a few limited health institutions are operating at maximum capacity to fulfil the needs of more than 4 million people in an unstable and unprepared area”, says Dr. Yasser Najeeb, Executive Director of an Immunization Group in Syria working under WHO to provide vaccines for children of the region, and working like many other groups to tackle the crisis in northern Syria, with support from WHO.

ARIJ’s reporter attempted to contact Dr. Munther Khalil, the Director of Idlib’s Health Directorate responsible for coordinating medical support in the governorate, who did not respond.

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600 doctors
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Dr. Muhammad Al-Salem told Arij, “In northern Syria, there are only 600 doctors serving over 4 million people, a third of which live in overcrowded camps on the border with Turkey. We need at least four times the current number of doctors to cope, and qualified laboratory technicians are very rare in the region. Moreover, the infrastructure has been completely destroyed, and most of the hospitals currently operating are relatively rudimentary”.

Dr. Mahmoud Al-Hariri added, “we fear there will be a great number of casualties among medical staff. As of September 8, we recorded 10 cases among medical teams, which forced them to remain in isolation for 15 days. For us, absent doctors is a big problem in light of their scarcity.”

There are only 90-100 ventilators available in the entire northern region of Syria, which are meant to serve 4 million people in normal conditions, excluding the pandemic or war. Of the total number of ventilators, 80 to 85 devices are already being used around the clock, according to Dr Al-Salem, leaving only a few devices spare.

In its 2019 annual report, the Syrian Network for Human Rights documented the death of 26 medical personnel and a total of 98 attacks on medical facilities in that year alone. The attacks were also confirmed in a report by Physicians for Human Rights, which recorded 595 attempted attacks on 350 separate medical facilities, with a death toll of 923 medical workers between March 2011 and February 2020.

According to Dr Hariri, WHO has formed a working group, under its direct supervision, for local organizations to fight the pandemic since March. The group operates in coordination with health directorates, and has a budget of $64 million for a period of six months.

Dr Al-Salem also indicated that Global Health provides safety equipment for workers in the medical sector, and more is scheduled to be sent in the coming months. It has also provided both online and in person training for medical personnel.

"Only four quarantine centers were equipped out of 30. Additionally, just four out of nine hospitals were equipped according to the medical plan initially drafted by medical organizations, with the support of WHO, to fight the virus," Dr Al-Salem added.

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Local Organizations

According to Mustafa Al-Hassan, the Protection Coordinator at the ‘Sadad’ Humanitarian organization, the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) allocated $11 million to support response projects, to increase hygiene in the camps, water sanitation and support the health sector.

It later announced a $75 million grant that would be allocated to organizations, subject to OCHA’s approval, and based on types of projects and plans. These funding figures have been confirmed and matched by three independent sources, but have not been published by OCHA itself.

For Al-Hassan, “the problem is that most of the organizations working in the humanitarian sector in northern Syria are not committed to pandemic prevention measures, and only a few are implementing the appropriate safety and awareness measures amongst their staff.”

Dr Al-Hariri insists that "no health system is capable of confronting the pandemic without social commitment to preventive measures, which is why it is imperative to equip hospitals and isolation centers. For example, the cost of equipping an intensive care bed can reach up to $13,000 while the cost of a mask is less than half a dollar, and it provides substantial protection and largely reduces the risk of infection.”

“However”, he continued, “the majority of the public does not comply with these simple preventative measures. We have even spotted some health sector workers who are not committed to wearing masks.”

ARIJ’s reporter found numerous instances of aid organizations not adhering to minimal preventative measures, such as wearing masks. Beyond the social media accounts of these organizations, which show staff in masks and adhering to the minimal standards, most of the fieldwork is conducted without the necessary health and safety precautions.

Director of the Maram Relief and Development Organization, Yaqzan al-Shishakli, indicated that since last April, his organization has established an isolation and quarantine center in the village of Sheikh Bahr in the countryside of Idlib.

The center provides services to those affected by COVID-19 in a well-equipped facility to ensure that the virus is not transmitted. Al-Shishakli said that as of September 1, the center has not received a single case.

“The center has a capacity of 160 people and is designed to double its size within a week in the event of an increase in cases, to accommodate up to 320 people. The center also aims to relieve pressure on local hospitals and coordinates with Idlib Health so that their work is under their supervision," Al-Shishakli told ARIJ.

Al-Shishakli confirms that his organization has provided several training sessions and workshops on safety and prevention measures, and that his organization has modified the attendance at schools it supervise from physical to e-learning, whereas most of the schools in northern Syria have completely shut down.

"We tried to complete the school year with our 4800 students online, and deliver all the lessons through WhatsApp. However, we faced some accessibility issues, because some families did not have access to WiFi and blackouts meant that the internet was not particularly reliable,” he added.

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Chaos and Clashing Authorities

In a region dominated by chaos and lawlessness, the authorities and military organizations seek to capitalize on the COVID-19 crisis without considering the dangers and consequences of the virus’ spread.

All decisions aimed at preventing the spread of the virus and issued by the Salvation Government (loyal to the Al-Nusra Front) which manages the city of Idlib and some parts of its countryside, have been superficial, according to Muhammad Haj Hammoud.

Hammoud, a Syrian journalist and Director of the Idlib Plus network, explains how efforts to fight Corona virus were ultimately driven by ulterior motives, as authorities aimed to increase their influence “on the ground” and to tighten their grip and power over civilians.

This investigation monitored a number of decisions that have effectively put civilians' lives in danger. For example, the decision taken on April 2 to suspend Friday prayers in mosques lasted only two weeks. This was a major issue, given that the month of Ramadan was observed in that period, meaning that prayers at local mosques continued day and night despite the danger of spreading the infection and in the absence of any preventative or precautionary measures.

Then, on May 31, Then on may 31, the local authority announced a penalty exemption for 2 weeks on outstanding car registration fees, encouraging people address previous registration payment defaults. This led to congestion when people rushed to re-register their vehicles forcing the government to extend the grace period to meet the demands.

This however, increased the risk of spreading COVID-19, and it was seen as a way local government was more interested in replenishing its coffers rather than prioritizing civilians safety and well being in the name of trying to normalise life.

Furthermore, the Salvation Government did not try to curb people movement, instead it tried to open new crossings and trade routes, which threatened to isolate Idlib and put it at risk of importing the infection from neighbouring areas.

Various sources ( in the Ministry of Health and elsewhere in the province), confirmed that as of June, Idlib’s neighbouring areas had already recorded at least 204 cases. This is despite numerous warnings issued by the Doctors’ Union in Northern Syria pleading not to open these crossings.

On April 15, the Headquarters of “Tahrir Al-Sham” group announced the opening of a commercial crossing with areas near the city of Saraqib, due to pressure from business owners and traders trying to compensate for losses they suffered as a result of border closure with Turkey. This too was a pretext as the group stood to gain from taxes imposed on all vehicles crossing, in either direction.

Demonstrations quickly spread in northern Syria, and several parties issued statements rejecting the decision and demanding that the crossing be closed. In response to the protests, authorities simply opened a crossing in a different area in the western countryside of Aleppo on April 30.

Tahrir al-Sham group published a video of the crossing’s activities and the entry of trucks from regime-controlled areas. Once again, the people protested by organizing a sit-in to express their opposition to the authorities’ decision. However, the authorities retaliated by shooting at protestors, killing some of them.

A worker in a local NGO, speaking on the condition of anonymity, indicates that “the most dangerous thing for humanitarian organizations operating in the northern regions is the interference of the local Government through the Office of the Displaced and the Office of Non-Governmental Organizations Affairs. Their approval is critical for the NGO’s operation in camps and they are usually capable of obstructions leaving people without needed aid and support”.

The deterioration of the economic situation, the collapse of the Syrian currency, the pandemic, and the implementation of the Caesar’s Act, led to more suffering and increased reliance of civilians on relief and humanitarian organizations.

Ahmed Abdel Hakim, a displaced person who lives in a camp on the Syrian-Turkish border in the western countryside of Idlib, explains how the aid he receives is crucial in sustaining him and his family. He told ARIJ that if the aid provided to him is cut for just one month, he and his family would face starvation and food insecurity, as he is unemployed and without any source of income.

On July 11, after great difficulty, the UN Security Council voted on Resolution No. 2533, which stipulates the renewal of the mechanism for the flow of cross-border humanitarian aid, specifically through the Bab al-Hawa border crossing that connects northern Syria and Turkey, for a period of one year. The resolution also called on the UN Secretary General to submit his report on the functioning and progress of the aforementioned mechanism to the Security Council at least once every 60 days.

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