SYRIA IN CONTEXT - CORONAVIRUS UPDATE #19

Dear friends and colleagues,

In recent weeks, Syria in Context has been making our COVID-19 coverage available as a free supplement in English, as well as in Arabic (with kind support from the Heinrich Böll Stiftung Middle East). Given the lack of independent and reliable coverage of the unfolding crisis, we think this is an urgent necessity.

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Emma, Tobias and Asser


Syria in Context will continue to cover the impact and response to COVID-19 in Syria throughout the coming weeks. You can find previous updates on our website.

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WEEKLY COVID-19 UPDATE

COVID-19 cases are on the rise in all areas of Syria, especially in government-held governorates. Last week, Syria in Context reported that the government’s figures vastly understate the scale of the outbreak and estimated that there are likely at least 85,000 cases in Damascus alone. Official figures continue to lag far behind reality–– with 2,109 confirmed COVID-19 cases in Syria as of August 18. Of these, 1,844 were recorded in government-controlled areas, including 73 deaths and 431 recoveries, while 1,271 cases remain active. The northwest has conducted 4,605 Coronavirus tests, 51 of which have returned positive. In northeast Syria there are 225 cases so far, representing rapid spread in the region (here too it is believed that the true caseload outpaces official figures).

Government-Controlled: The situation in Damascus remains critical. According to the Ministry of Health, there are 1,764 registered cases, of which 73 people died and 431 recovered; that leaves 1,271 cases active. Syria registered nearly 600 cases in one week, which is more than what it registered in the first five months after the appearance of the first case in the country in March. 

Two weeks ago, Syria in Context first reported that the outbreak was overwhelming healthcare capacity and had significantly outpaced the official figures. Since then, working with Imperial College, it has been possible to interrogate all of the available data. According to Oliver Watson, MRC Centre for Global Infectious Disease Analysis, J-IDEA, Imperial College London, for every COVID-19 death reported in Damascus, there are an estimated 50-100 deaths that are not being reported. The modelling work is being refined, and Syria in Context will bring you updated information as it is available in the coming weeks. Mr. Watson explained the work and methodology: "In response to the reported number of deaths from the Damascus mortuary office between the 25th July - 1st August, we have conducted a preliminary analysis into the extent of under-reporting of deaths in Damascus. Using a similar framework to the one deployed for modelling healthcare burden in Low- and Middle-Income Countries, we have started extending our approach to model the proportion of deaths that are not reported. These estimates are then used to compare our predictions of mortality due to COVID-19 in Damascus to estimates of excess mortality between 25th July - 1st August. By incorporating a constant level of under-reporting throughout the epidemic in Damascus, we assume that the reported deaths to date (44 deaths in Damascus governorate as of 17th August) are representative of the shape of the epidemic in Damascus.

We estimate that to date, for every one COVID-19 death reported in Damascus, there are an estimated 50-100 deaths that are not being reported. These estimates are robust to varying sensitivity analyses relating to the effectiveness of interventions that have been implemented in Syria and Damascus as well as our working assumptions of the excess strain that COVID-19 will have placed on healthcare systems in Damascus. This level of under-reporting in Damascus leads to a very different picture of the extent to which COVID-19 has spread within Damascus, with an estimated 60,000 - 100,000 active infections in the Damascus region.

It is important, however, to highlight that there are a number of assumptions that we have had to make to arrive at these numbers. We hope to refine these assumptions in the coming weeks to give a more complete understanding of the epidemic in Damascus. Caveats aside, it is hard to argue against a large degree of under-reporting of COVID-19 deaths in Damascus. The data provided by the Damascus mortuary office, however, has provided us with an invaluable source of data. We would encourage and welcome more sources of similar data to help refine estimates of the scale of the COVID-19 pandemic."  

In response to Syria in Context’s findings, the United Nations Damascus office stated in their most recent COVID update that they are not “well-placed” to verify the claims they had received that challenge official figures. In what is widely seen among Damascenes as an attempt to hide the scale of the outbreak, the Damascus governorate announced that community prayers would open again from the weekend. One commentator quipped that they “wished to hurry people to paradise.”

One factor with the divergence between official figures and reality is the low levels of testing taking place in the country. According to the latest UN update, the Syrian Ministry of Health’s testing is returning a mere 5.9% positivity rate. However, when we compare the stated average daily tests and average daily infections, the resulting rate should be closer to 15%. Presently, just 509 tests are being conducted per day according to the UN. This week, the government announced that 300 tests per day would be available to those leaving the country, at a cost of $100 each. A new site was opened late last week for the paid tests at Al-Jalaa sports stadium, which was quickly overwhelmed. Photos and videos of large angry crowds at the site quickly spread through social media. Since then, the MoH has hurriedly opened new testing sites for these paid tests. Even with the additional sites, the number of daily tests is so low as to be inconsequential in the face of the outbreak. 

With testing limited and hospitals in the capital overburdened, doctors have taken to social media to diagnose those afflicted with COVID in Damascus. Through Facebook groups and pages, doctors in Syria and abroad are running small projects designed to provide information, diagnosis and advice, to patients with symptoms ranging from anxiety to serious Covid-19 infections. In the comments, locals advise each other to take the sick to other cities outside of Damascus where beds may be available. The price of oxygen canisters in Damascus has risen by up to ten times due to the large numbers of people treating Coronavirus cases in their homes. Local medical workers have reported that patients are required to bring their own oxygen to the hospitals.

While we were, for lack of data, thus far only able to model the scale of the outbreak in Damascus, the virus continues to spread rapidly throughout government-held areas. Of the 251 cases officially registered between Sunday morning and Tuesday night, 61 were recorded in Aleppo, 45 in Latakia, 61 in Damascus, 14 in Sweida, 23 in Homs, 19 in Damascus Countryside, 9 in Hama, 9 in Hasakah, and 9 in Tartus. A total of 13 deaths were registered during those three days, four of which were in Damascus, three in Homs, one in Aleppo, two in Deir Ezzor, two in Hasakah, and one in Hama. Considering that other governorates are no better prepared to meet the virus, we expect a trajectory similar to Damascus, where a rise in severe cases requiring hospitalization will quickly overburden healthcare capacity leading to a steep rise in mortality among those who cannot access care.

The Governor of Sweida, Houmam Dbeiat, expected the number of COVID-19 cases in his governorate to reach their peak in the coming ten days, though it is not clear why he believes this to be true. He said that 17 to 27 swabs are taken every day in the area, which is far fewer than is needed to keep on top of the outbreak. At the time of his remarks, there were 78 recorded cases recuperating at home and 23 cases isolated in the hospital. There have been six reported Coronavirus-related deaths in Sweida so far. Sweida residents have been calling for resisting any attempt to send children back to school, as they say, hospitals in Damascus cannot care for those who are sick. 

In Hama, an outbreak in the village of Karnaz was recorded early last week, with possibly 100 people affected. Residents of Hama have complained that no testing sites are available in the area, despite the rapid spread of the virus. Likewise, the Latakia outbreak continues to spread out of control, with 154 official cases recorded. The first medical worker in the province, a popular pediatrician, passed away during the week. 

According to OCHA and the WHO, 69 of the confirmed Coronavirus cases in Syria thus far have been healthcare workers, most of them in Damascus. However, lists bearing the names of all the medical workers who died of the virus are being shared online, in addition to individual obituaries that have flooded Syrian social media. According to these local reports, Syrian healthcare staff is being ravaged by the virus. At least five doctors and one pharmacist died of COVID-19 in Aleppo on August 14 alone. On August 11, Dr. Tayseer Sabbagh, the Regional Director of the UNRWA Health Programme, died of COVID-19 at Al-Kindi Hospital in Damascus. UNRWA reportedly has many symptomatic staff members. The high fatality rates among medical workers suggests there is a chronic lack of PPE and preventative protocols for those working closely with Coronavirus patients. Local medical reports that they are required to purchase their own PPE and are tempted to reuse it in order to save money.  Syria can ill-afford to lose so many medical workers, having lost a significant portion of the workforce in the period during the war.

Northwest: Tuesday saw the first Covid-19 death in the northwest when an 80-year-old woman with kidney problems died at a hospital. There were no new positive cases reported in the northwest in the period from August 14-17, though the number of confirmed cases was up to 54 by August 18. Local authorities continue to struggle to trace and test all known contacts of the infected: Of 656 contacts of known cases, just 371 have been tested (out of a total of 4,605 tests conducted in the region thus far). Two cases in Bab al-Salam IDP camp have now recovered, though measures remain in place to prevent further spread in the highly vulnerable area.

In an effort to save intensive-care capacities, the prevention strategy in Idlib focuses on treatment for the estimated 14% of positive cases who require medical care but are not suffering symptoms severe enough to wanton transfer to the ICU. Idlib has only 84 available ventilators, despite the WHO’s plan for the area highlighting the need for 159. Supplies of all PPE for medical staff, as well as general hospital supplies remain low in the area.

In general, prevention is still proving challenging across the northwest. Nearly 50% of people report being unable to afford masks for themselves and local officials admit that they are not available to purchase in the markets anyway. This week, the Interim Government made mask-wearing in public mandatory but said the SIG will provide these free of charge over a period of time. Other measures include the closing of internal crossing points, banning of large public events and celebrations, social distancing in markets and other communal spaces, reducing medical services to emergencies, among other things. Maintaining a low caseload is essential in the area, as the health service will rapidly become overwhelmed if the virus spreads. 

Northeast: There are 225 COVID-19 cases in northeast Syria, 14 of them have died and 28 recovered, leaving 187 active cases. At least 15 cases are health workers. 14 cases were announced on Tuesday, of which eight were in Qamishli, three in Derik (Malkieh), two in Amuda, and one in Kobane. The most recent COVID-19 death was a woman in her 70s who passed away on Tuesday in her city of Derbasieh. It is widely believed that the true number of cases in the northeast far outstrips the number of recorded cases. A local organization says more than 50% of locally administered tests have returned positive, suggesting the caseload is high, though it is difficult to say how high due to the lack of testing and lack of coordination between the different testing mechanisms in the area. 

On August 16, the AANES made wearing a mask compulsory in all public spaces starting Tuesday, August 18, imposing a 1,000 SYP penalty on violators. Just 7% of residents in NES have been wearing masks, according to recent research. 

Due to the large number of people who travel by plane between the Damascus and Qamishli airports, military cargo planes are used in addition to airliners. Photos circulating on social media showed people stuffed “like pickles in a jar”, as one Qamishli resident put it, in the military plane. Many have started to believe that these planes are bringing COVID-19 cases from Damascus to NES. There are reportedly no checks being done on those arriving at the airport which is under the control of the Syrian government. Local media also says that there are at least 15 informal crossings with government-held areas in al-Shuhail area of Deir Ezzor alone; hundreds of people enter from NES through such crossings every day, also unchecked.  

Meanwhile, five COVID-19 cases have been registered among health workers in the Al-Hol IDP camp, where women and children believed to have links to ISIS, or who were living in ISIS final strongholds, are housed. No cases have been registered among the camp's residents. However, 24 people in the camp who had previously interacted with the infected health workers were tested and the results all returned negative. The outbreak in the IDP pocket of Shebha has now reached at least 30 cases, according to local sources.

Neighbouring countries: Lebanon has recorded 9,337 COVID-19 cases, with 105 deaths and 2,809 recoveries. The daily number of recorded infections continues to soar as the Lebanese Ministry of Health registered 456 cases on August 17. The next day, the Lebanese Caretaker Minister of Interior and Municipalities instated a lockdown and partial curfew in order to try and curb the spread of the pandemic. According to the decision, private establishments, commercial markets, companies, marketplaces, seaside walkways, gyms, restaurants, cafes, bars and all places of public gathering will be shut down from August 21 to September 7. A daily partial curfew will stretch from 6pm to 6am every day during that period. The airport will remain open. The lockdown measures will be especially difficult, as the country remains in crisis following the port explosion. Many in Beirut do not have windows or regular food. 

In Turkey, cases continue to grow, with 250,542 cases recorded, leading to 5,996 deaths and 231,971 recoveries. The caseload remains high in Ankara and along the Turkish-Syrian border areas, where the number of cases is believed to be far higher than the official figures. In Iran, 347,835 cases of COVID-19 have been recorded, with 19,972 deaths and 300,881 recoveries. Iraq has 153,599 cases, of whom 5,464 died and 109,790 recovered. In Jordan, there have been 1,398 cases of COVID-19, with 11 deaths and 1,241 recoveries. As of Saturday, Jordan instated a daily partial curfew between midnight and 6am, and imposed wearing masks on all its residents in public spaces. Anyone who breaks the curfew or does not wear a mask would have to pay a penalty or go to jail for up to one year. Jordan decided to shut down the Jaber border crossing with Syria for one week, starting August 13, in order to prevent a spillover of COVID-19 into the country.

COVID-19 Key Reads: 


Syria in Context will continue to cover the impact and response to COVID-19 in Syria throughout the coming weeks. You can find previous updates on our website.

We are a wholly subscriber-funded publication. If you have found this update useful, we encourage you to consider joining our growing community:

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SYRIA IN CONTEXT is a subscription newsletter edited by Emma Beals and Tobias Schneider and written with Asser Khattab. You can follow us on twitter @SyriaContext or email us.

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