Public Health as a Weapon: Syria and COVID-19
COVID-19 has almost certainly reached Syria. The extent of the infection, however, has been completely shuttered from the outside world. Officially, the Syrian government claims zero confirmed cases, but the claim appears improbable given the spread of the virus across all of Syria’s neighbors. Notably, population movements, including high-level officials and fighters, continue between Syria and Iran, even as Iran became the second hardest-hit country in the world. On March 10, the Pakistani Heath Minister said that six Pakistani nationals tested positive for the virus after returning from Syria. As of March 11, some rumors estimate the number of infections at more than 2,000 cases. The Syrian government later announced sweeping preventative measures, including the suspension of all universities and schools, but maintained that zero cases were present.
“The situation in Syria is already too desperate; the need is so great. If an outbreak hits Syria, particularly in the northwest where millions of people are living in open-air shelters without access to medical care, we will have a humanitarian catastrophe beyond reach” says Diana Rayes, a public health specialist at the University of California, Berkeley and steering committee member of the Syria Public Health Network. “The most important thing in terms of public health is to be preventative rather than reactive,” she notes. This is why the government’s current denial of cases inside Syria is dangerously self-defeating, as it is preventing any effective measures to contain the virus, and may also limit Syria’s access to emergency resources from external donors. It is difficult to analyze the government’s response without more verifiable information to provide a clearer picture of what is happening. However, the government is likely censoring information in large part to minimize criticism over its capacity to deal with the crisis.
At present, only one laboratory in Damascus is designated for testing COVID-19 in the country, while only 57 public hospitals (67 percent) are operating at full capacity inside Syria. After nine years of war, critical health infrastructure, medical equipment, and medicine are lacking, as are the number of doctors and nurses across the country. Even before the COVID-19 crisis, the government’s capacity to detect and limit communicable diseases was woefully inadequate. One physician who had worked inside Al Assad Hospital, one of the largest hospitals in Syria, noted that the facility was using faulty test kits and expired medicines to test and treat cases of the H1N1 virus throughout the war.
1) Few notes on the capacity of #Syria Gov to deal with #COVID19. I was a physician working in Damascus hospitals' emergency departments and ICUs in the past. For quite good time, I used to manage suspected #H1N1 and severe #flu cases with respiratory failure.
— Nour Audi (@Nour__Audi) March 8, 2020
The denial and attempted cover-up of an epidemic are not unprecedented on the part of the Syrian government. Vaccination coverage inside Syria has dropped precipitously from pre-war levels of around 80% to less than 50%, leading to the emergence and spread of infectious diseases previously eradicated or contained. In October 2013, cases of polio reappeared in Deir Ez-Zor 18 years after it was eradicated from the country. The governorate, then under opposition control, had been excluded (likely under government pressure) from the World Health Organization’s polio vaccination campaign the previous year. Damascus initially denied the presence of the virus, but the cases were quickly tested and confirmed by the U.S. Center for Disease Control and Prevention (CDC) and Turkish authorities. By the end of October 2013, WHO had publicly acknowledged the outbreak, and by May 2014, it had declared polio a global health emergency.
The Syrian government was compelled to work with WHO on a regional Polio Immunization Campaign to mitigate the crisis. However, Damascus’ position in the effort was a disturbing testament to its willingness to use public health as a weapon against the opposition. WHO in Syria, which requires permission from the Syrian government to work inside the country, was handicapped from implementing the vaccination campaign in besieged and opposition-controlled areas. A Polio Control Task Force (PCT) was subsequently formed by eight Syrian and regional NGOs, including the Assistance Coordination Unit and the Syrian American Medical Society (SAMS), in order to provide vaccinations in areas inaccessible to WHO, helping to stem the outbreak. However, the Syrian government continued to use the crisis against opposition populations. In 2017, for example, the Syrian government likely perpetrated an attack against a vaccine storage facility in the Al-Mayadin district of Deir Ez-Zor, destroying at least 140,000 doses of vaccines. Al-Mayadin had been the epicenter of a new polio outbreak just a few months prior.
Similar discrepancies in Syria’s response to COVID-19 and its weaponization of the crisis through neglect is probable in the current context. “The main issue inside Syria is the lack of a uniform health system which can scale-up preparedness and response across the country,” says Rayes. While the WHO in Syria has made swift and laudable efforts to support the Syrian Ministry of Health in preparing for a coronavirus outbreak–by preparing quarantine units, providing medical supplies, and conducting trainings–all of its efforts remain limited to government-held areas. In opposition territories, the outbreak response will again fall upon Syrian and regional aid groups. There, they face overwhelming obstacles–a massive humanitarian disaster which is already overwhelming relief efforts; more than one million people displaced and many living in temporary shelters and open-air; and a deliberate campaign against medical facilities by Syrian and Russian forces which has destroyed 84 hospitals and medical facilities since December 2019.
The coronavirus pandemic has forced the world to realize that the public health of the global community is interconnected. Such a crisis should provide Russia and China enough incentive to end its efforts to limit the flow of international aid to opposition held-areas and pass a UNSC resolution to reauthorize recently closed cross border aid deliveries from Jordan and Iraq. Western countries should also evaluate existing sanctions that may impede, directly or indirectly, the delivery of critical medical equipment and supplies inside Syria. The rest of the international community must also act swiftly to increase aid and resources, not only to WHO’s activities in government-held areas but to NGOs working among the most vulnerable populations in the North. Finally, WHO and other international aid agencies working with the Syrian government has a responsibility to push back against misinformation propagated by the Syrian government. Without swift action from the international community, the spread of coronavirus in Syria will be catastrophic for the country and the region and will impede global efforts to contain COVID-19 in the long term.
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