Syria in Context Investigation: COVID-19 Spreads out of Control in Damascus
Pandemic reaches crisis level in Syrian capital
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In recent weeks, Syria in Context has been making its 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.
We are a wholly subscriber-funded publication. If you have found this update useful, we encourage you to consider joining our growing community by subscribing.
INVESTIGATION: PANDEMIC SPREADS OUT OF CONTROL
The COVID-19 outbreak in government-controlled areas of Syria is now out of control and overwhelming the limited capacities of the war-torn country’s health care sector. In today’s update, Syria in Context estimates that over the past week, the Damascus region alone likely suffered hundreds of excess deaths attributable to Coronavirus, suggesting that tens of thousands of residents of the capital may have already been infected. These estimates, based on local reporting and our own supplemental investigations, outpace the official numbers released by the Syrian Ministry of Health and the World Health Organization (WHO), which record a mere 944 confirmed cases and 48 deaths, by orders of magnitude. Local health services, suffering shortages of protection equipment (PPE) and tests, as well as rampant corruption, are already overwhelmed.
As it becomes increasingly clear that the virus is far more prevalent than is being reported, an urgent increase in supplies and a radical change in approach to mitigating the outbreak, as well as increased transparency, are needed to prevent the growing catastrophe.
As the government fails to grapple with the crisis, ordinary Syrians have relied on personal stories and rumours, shared via social media, to get a sense of the scale of the pandemic. Over the last week, what started as quiet murmurs has grown into a constant and deafening cry for help from a population seeing large numbers of their family and friends falling ill and unable to access healthcare. One famous Syrian TV reporter took to Facebook and said he knew of 20 cases and requested people to reply in the comments how many cases they knew in their own circles. Among a dozen sources spoken to by Syria in Context, multiple reported deaths or serious illness among their own family, while all said that a significant number of those they know have a suspected coronavirus case in their family or immediate circle.
In the absence of reliable data, Syria in Context is forced to try and infer the scale of the outbreak from available information. According to the director of the Syrian “Board of Deceased”, deaths in the country had been growing exponentially since 10 July. Indeed, social media pages collecting obituaries from the Damascus region have recorded a steady rise in deaths, reaching 49 new posts on August 1 and 52 on August 2. In response to rumours of growing numbers of deaths, the Damascus Governorate office of the deceased announced it had recorded 107 deaths on August 1; 104 the day July 31; 127 on July 30; and 133 on July 29. Comparing these numbers with average daily deaths in the capital in prior years, said to be around 25 in 2016, suggests a range of 79 to 108 excess deaths in the capital over the past weekend. These numbers are further substantiated by the claims of a doctor at one of the principal COVID-19 hospitals in the country who says he recorded 800 deaths at his facility in just one week.
Entering the lower-range estimate for daily COVID-19 deaths over the past week into the Imperial College London model for COVID-19 transmission in Syria, we estimate that at least 85,000 locals in the Damascus region are infected with the virus. This conservative number roughly aligns with the order of magnitude provided by local Associate Health Manager Dr. Ahmed Habas who was quoted this week with an estimate of 112,500 active cases in Damascus. While these numbers cover only the capital region, the outbreak has also spread to other governorates with Latakia, Aleppo, Deir Ezzor and Sweida recording new cases - though the available data do not permit similar estimates.
Unfortunately, the WHO stopped releasing its weekly “EWARS” updates tracking incidents of flu-like and respiratory illnesses in the country in mid-March, immediately prior to the appearance of the first official Coronavirus cases in Syria. EWARS represents the most dependable metric for humanitarians and observers to identify any undetected Coronavirus outbreaks.
While the government may seek to obscure the scale of crisis through bureaucratic means, such as registering virus deaths as “heart attacks”, Syria in Context has been able to follow the trail of the deceased, by way of the place of burial on their death certificates, to the area of Najha on outskirts of Damascus, where it is likely that the majority of Coronavirus deaths are being buried. The location was independently verified by sources in Damascus who confirm that both an existing cemetery, containing Syrian Army war dead, as well as a new cemetery in the area have been the locations of the recent burials. Syrians confirm that families can pay for their loved ones to be buried in more traditional cemeteries around Damascus, while those who cannot pay, or who remain unclaimed, are buried in Najha which houses several of the Syrian government’s preferred burial grounds for the poor, fallen military conscripts, as well as prisoners killed in its notorious prison archipelago.
Indeed, satellite images provided by Maxar Technologies show significant amounts of burial activity in the new Najha cemetery on both June 27 and August 4. Najha cemetery covers a large area of land, far bigger than the smaller graveyards found elsewhere in Syria. It is divided into sections, each of which contains smaller blocks of graves assembled in 12 rows of at least 16 graves. On August 4, nine vehicles––three of which appear to be ambulances or vans––can be seen next to a row of freshly dug graves that spans two blocks. At least 25 objects, which appear to be coffins are scattered on the ground among the shadows of people. A similar scene appears a few weeks prior, on June 27. Analyzing images of the graveyard, believed to be from late January, suggests that at least four blocks of graves, and 13 additional rows, have been filled in the last few months. Other cemeteries in the Najha area have increased in density in the last few months as well.
Najha Cemetery, August 4, 2020. Satellite image ©2020 Maxar Technologies.
Najha Cemetery, June 27, 2020. Satellite image ©2020 Maxar Technologies.
The scale of the outbreak has overwhelmed the country’s fragile health system. Last week already, two major humanitarian groups, Mercy Corps and World Vision, had warned that the healthcare system in Damascus was beyond capacity. Indeed, according to the Imperial College model above, the expected number of new hospitalizations per day at the rate of infection believed to be prevalent in Damascus is 1,763 with 443 cases that would require intensive care. Syria is believed to have no more than 300 critical care beds in government-controlled areas in total, meaning the worst-affected areas in the capital are likely to have already exceeded its capacity by some measure. Experience from other hotspots around the world suggests that case fatality rates begin to climb dangerously the moment local hospitals are overwhelmed and forced to triage patients.
Healthcare workers themselves have been disproportionately affected by the outbreak with numerous coronavirus cases reported among medical staff in recent weeks. These medics, who work in stressful circumstances as they see their colleagues succumb to the virus, are beginning to speak out. Last week, one said on Facebook: “We have practically reached the stage of the spread of the pandemic, whether or not the Ministry of Health approves it. There are many injuries in the homes, and most of the people are unable to secure oxygen and primary care for patients due to the cost and scarcity of oxygen.” Another blamed the Ministry of Health as well, calling their underreporting of the epidemic “scary reckless.” The Dean of the Faculty of Human Medicine in Damascus, Dr. Nabogh Al-Awwa, broke ranks with the official line and said that: “The country is experiencing a major spread of the Coronavirus, and has begun to spread (ascending) which was not counted... The percentage of infections among Syrians is very scary;" before going on to say, ′′one hundred infected people reach hospitals a day."
Many who spoke to Syria in Context said those they know who were suffering from what they suspect is the virus were not even attempting to access hospitals, as they are known to be overwhelmed. Corruption is prevalent every step of the way with some sources saying they used money and connections to gain access to hospitals for sick relatives. They went on to say that those who paid their way into medical care were being admitted into regular rather than dedicated COVID19 wards, thus potentially exacerbating the spread of the disease among vulnerable patients. One Damascus resident, speaking on condition of anonymity, said that "of course [they are] not admitting most cases to any hospital unless desperate and unable to breathe … and only if lucky and a ton of cash and connections.”
Indeed, besides the suppression of information, the government’s Coronavirus response continues to suffer from apparent mismanagement and corruption on all levels, including in the crucial area of testing. While the WHO reports that the Syrian Ministry of Health had conducted 12,416 tests across government-controlled Syria by July 24, multiple residents of Damascus report not being able to access PCR tests themselves. Others believe that the regime was, in fact, hoarding testing kits for those who could pay or who have high status within the government. Another source said tests were available only to those willing to pay for the $100 tests for a clean bill of health necessary to leave the country, a suggestion supported by the Ministry of Health which announced on Tuesday that it was increasing the opportunities to take the paid tests. One person, who did manage to get tested, reported a 3-5 day waiting period for results, while another reported waiting one week. Another source said the tests were unreliable and highlighted a case where a test taken in Syria was negative, but another test taken by the same individual on arrival in another country was positive. Government officials were apparently attempting to deflect blame for the shortage, telling patients that the shortages in tests were due to Western sanctions.
According to the WHO, the organization has provided Syria with “enzyme kits (31,240 reactions), extraction kits (27,250 reactions), screening kits (57,792 reactions) and confirmatory testing kits(1,920 tests), 52,000 swabs and viral transport medium for sample collection, and five polymerase chain reaction (PCR) machine.” Other tests have arrived in limited numbers from both China and Russia. Private businessmen have attempted to bring tests into the country but have not yet been able to do so due to bureaucratic issues. Humanitarians and western states report that attempts to increase supplies to Damascus have faced delays or rejection.
Locals and health workers report similar difficulties sourcing medical and protection equipment. Despite the 2.5 million pieces of PPE reportedly provided to Syria by the WHO, sources report families having to purchase equipment for medical workers. Another described how the nurses who had treated their relatives in their home did not have PPE and had been coughing throughout the treatment. Meanwhile, advertisements for personal ventilators have appeared on Syrian social media and overwhelmed medical staff are advising those with symptoms to treat themselves at home using this equipment if they can afford it.
The Syrian government has also struggled to implement and sustain prevention measures, as the country has suffered a simultaneous economic crisis, further immiserating millions of Syrians who now find themselves in an impossible position, with even formerly middle-class Damascenes now living in cramped quarters, queuing for essential goods and dependent on work outside the house. As one Damascus local reports: "People are unable to socially distance themselves while they need to stand in endless queues to receive the meagre subsidies they need. And they are not taking any measures - masks are damn expensive!" Elsewhere, residents appear to not be taking the virus seriously, with video of crowds of revellers at a recent Tartous beach party circulating on social media.
Those inside the country blamed the lack of compliance with public health measures on the lack of reliable and coherent public messaging. They also describe a general sense of fatalism about the virus after ten years of war and an economic crisis. A number of sources seemed to believe that the government was no longer attempting to contain the virus but was headed for “herd immunity” - letting the virus rampage through the population until a large share of Syrians had recovered and acquired immunity. Discouraged by the WHO, such a passive approach, effectively abandoning intervention, would inevitably lead to high death counts among the population. It further remains unclear to what degree and for how long Coronavirus antibodies imbue the carrier with immunity and what other long-term health effects milder cases of the virus might incur. “Herd immunity” would thus remain a reckless gamble with Syrian lives and there is no signal from the Syrian government that it is the strategy, but rather a local justification for a lack of intervention.
Northwest: As of August 5, there are 40 confirmed COVID-19 cases in the north-west, with 3,633 tests completed. 15 people have recovered, according to the Interim Ministry of Health. As of July 19, local health authorities had been able to trace 366 contacts of patients who tested positive, 231 of whom have been tested. No one has died of COVID-19 in Idlib yet. The Northwest, which hosts hundreds of thousands of internally displaced in crowded camps, remains highly vulnerable to a pandemic outbreak.
Sarmin remains under quarantine after a case was identified in the town. The border between Turkey and Syria was open over Eid, as Syrians living in Turkey were allowed to visit their family for the holiday. The border had previously been shut to prevent infection reaching the area. Health workers reported a lack of compliance with preventative measures over the Eid holiday and fear a spike in cases may be seen in two weeks as a result. Local awareness campaigns have been scaled up in an effort to promote social distancing and hand washing to prevent the virus spread. Removing even mild cases to treatment centres is particularly crucial in the northwest due to the precarious and high-density housing of the displaced population in the area. The UN reports an urgent need for more tests and lab capacity within Idlib, to keep up with the increasing demand required to keep a handle on the new outbreak in the area.
Northeast: Five new COVID-19 cases were registered on Sunday in northeast Syria, raising the total number of cases to 36, after 17 cases were announced on Thursday. The co-chair of the Autonomous Administration of North and East Syria’s (AANES) Health Department, Juan Mustafa, said that, of the new cases, four are men and one is a woman, all of them in Hasakah city. A number of the cases reported in late July had no contact with each other and no travel history, sparking fears that there is community spread within the NES beyond the reported cases. Testing remains a difficult issue in NES, with additional local testing capacity urgently needed.
On August 4, the AA announced that a total curfew will be imposed in NES for a week starting Thursday, August 6. An exception will be made for shops and grocery stores, public and private bakeries, pharmacies and hospitals, gas stations, and aid organizations. On August 1, the AA announced a strict lockdown on Tabqa area, closing off all entrances and exits before anyone except medical emergencies and commercial activity. It also banned gatherings altogether in the entire region it controls, including swimming pools, cafes, prayers, and weddings, and allowed restaurants to serve takeouts and delivery only. The administration of Semalka border crossing allowed a total of 250 people who have residency permits in Kurdistan to cross into the region on Tuesday, Wednesday, and Thursday this week.
Neighbouring countries: Lebanon has recorded 5,062 COVID-19 cases, with 65 deaths and 1,837 recoveries. Prior to the blast in Beirut, COVID-19 was reaching critical levels of healthcare saturation according to the Director-General of Rafic Hariri University Hospital, the main medical establishment treating COVID-19 cases, who had 19 critical patients and a bed capacity of 23. There are also 55 other patients who are either infected with the virus or are suspected cases; the bed capacity for these is limited to 80 beds. Following Tuesday’s blast, lockdown measures were cancelled and hospitals overwhelmed with trauma patients. It is highly likely a spike in cases will follow Tuesday’s disaster.
In Turkey, 233,851 cases have been recorded, leading to 5,747 deaths and 217,497 recoveries. Turkey’s Interior Minister tightened rules on Tuesday after new daily cases jumped above 1,000 for the first time in three weeks. In Iran, 312,035 cases of COVID-19 have been recorded, with 17,405 deaths and 270,228 recoveries. An investigation by the BBC’s Persian service that locked into the government’s records revealed a coverup on the number of cases and of deaths, stating that there are actually 451,024 recorded infections and 42,000 deaths. Iraq has 131,886 cases, of whom 4,934 died and 94,111 recovered. In Jordan, there have been 1,218 cases of COVID-19, with 11 deaths and 1,131 recoveries.
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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