During a decade of war, many millions of Syrians have been torn from their homes, businesses and incomes, and uprooted again and again due to repeated conflict. A year ago, a further million were forced to flee within northwest Syria, the single largest displacement of people during the conflict.
Now they face three interlinked crises: increasing coronavirus cases; freezing winter temperatures in crowded, flooded displacement camps; and economic disruption making work, and food, harder to find.
The most vulnerable have been displaced not once or twice but three or four times, and on occasions many more, according to Dr Mahmoud Daher, head of the WHO’s field presence based over the border in Gaziantep, southern Turkey. Covid-19 is another deadly condition for people to face on top of all other hardships.
In northwest Syria, the position is particularly acute. Here, 2.7 million displaced people are confronted by a dire situation, with more than 1.5 million living in overcrowded, muddy ‘last resort’ sites, with inadequate water supplies and sanitation.13 Winter is harsh in Syria with freezing temperatures, strong winds and heavy rain leading to flooding. Already one child has died and three people have been injured in January flooding and DEC charities fear that, with far more people living in flimsy shelters, many open to the elements or under water, there will be more.
Experienced aid workers describe the combination of these three crises as “absolutely terrifying” and “a perfect storm”, at a time when humanitarian funding is in decline.
The true picture of coronavirus in Syria is hard to determine but is becoming clearer as testing increases.
Officially, as per the WHO Syria dashboard, by late February 2021 there had been 15,282 cases and 1,004 deaths in the government-controlled areas of the country, and the Ministry of Health has reported an acceleration in cases since October.
In mid-December, the government said that an average of 571 tests were being carried out daily in its laboratories but, when the DEC Response Review analysis was carried out, it found no adequate Covid-19 monitoring and reporting mechanism in place and said the real health impact of the pandemic is unknown. The aid community on the ground believes exact numbers far exceed official figures and that significant numbers of asymptomatic and mild cases are going undetected.
In the non-government controlled areas, figures are higher. In northwest Syria the WHO reports more than 20,000 cases and media reports in the autumn said cases in the camps were “rampant”.14
Cases have increased 10-fold since then, according to DEC member charity World Vision, with a spike in November and December, 2020 mostly due to increased testing.
Numbers of deaths from Covid-19 are hard to estimate given people move so frequently. Alexandra Matei from World Vision Syria Response says: “It’s hard to know about the death toll – people in Syria are moving all the time. We had one family that had moved 10 times, so it’s hard to keep a track of people in a crisis on the move and what the data is.”
There is also a mixture of denial, fatalism and stigma about Covid-19 in the country, so people do not access testing and healthcare, further skewing the figures. The WHO’s Dr Mahmoud Daher says people think Covid-19 won’t affect them, believing they have been through so much that they will have a high immunity. “People have experienced war zones, they have already had terrible events in their lives, and they feel how can this abstract situation trouble their lives,” he says.
DEC members agree that this attitude, while understandable, creates challenges. World Vision’s Alexandra Matei says: “People don’t fear the virus, they’ve been living in fear for a decade with bombing, displacement and all the fragilities that come from living in a conflict. Then you add coronavirus and they just want to get on with their lives, they might be dead tomorrow.
“They don’t quarantine or seek treatment because of stigma and fear, so you have people going around the packed camps with Covid. So, it’s a medical crisis, putting children and families at risk.”
Despite many people choosing not to access healthcare, there is evidence that Covid-19 is overwhelming some services. In government-controlled areas more than 50% of its medical facilities are dysfunctional and Covid-19 has overstretched the limited capacity.15
In northwest Syria, the WHO’s Dr Mahmoud Daher says some hospitals have been overwhelmed in Idlib with few ventilation facilities, oxygen supplies, oxygen concentrators and intensive care units. NGOs have also voiced concern over a lack of pharmaceutical supplies such as antibiotics due to closed borders.
NGOs have also voiced concern over a lack of pharmaceutical supplies such as antibiotics due to closed borders.
World Vision’s Alexandra Matei says there are now 10 times the number of Covid-19 cases compared with the autumn but only double the number of ICU beds.
She added: “Previously there were around 114 ICU beds, and now with increased Covid cases and medical needs, you have just 232 beds. The beds have increased by 100, in terms of the numbers, but this isn’t enough when you have 10 times the cases.
"World Vision immediately responded to these critical needs and bought ICU beds, oxygen units, masks and everything that was necessary to expand the ICU unit. But what we're hearing is that people are still dying because there are not enough ICU beds."
Health workers have felt compelled to work and have paid the price. Thousands of healthcare professionals have fled the country over the past decade – 70% of the workforce – leaving doctors, nurses and other health workers in scarce supply. As a result, those that remain in the country have continued to come into work even with suspected or confirmed Covid-19 themselves because they are so desperately needed. In northwest Syria, for example, there are only two ICU specialists.
The DEC’s Response Review highlights a shortage of PPE in northwest and northeast Syria and said medical staff are permanently exposed to high risks. Around 15% of confirmed cases in northwest Syria were either clinicians or support staff in the health service, Dr Daher says.
The pandemic struck as Syria was already suffering a major economic crisis, with Covid-19 causing further deterioration. Preventive measures have had a negative economic impact, with most businesses reducing or suspending their activities which has had a knock-on effect on jobs and informal labour. The global downturn has affected Syria too, and the closure of borders has affected trade. This has been the biggest impact of Covid-19, according to the WHO’s Dr Mahmoud Daher.
Inflation of the Syrian pound has soared and the prices of foodstuffs in October 2020 had increased by a dramatic 247% compared to a year ago.17 In addition, other factors such as shortages of staple foods have led to widespread food insecurity across Syria. Vital supplies such as fuel for heating and transport are also in short supply.
World Vision’s Alexandra Matei said in late February 2021: "The Syrian pound reached the lowest point of devaluation a couple of days ago and this means that people’s purchasing power is limited to almost zero now. So, it’s not just the bombs it’s everything they are going through.”
Many in the displacement camps rely on informal daily work, such as agricultural work and selling vegetables in markets, and are experiencing shortages of cash to cover their basic needs.
With no government safety net, Syrians are reliant on going out to find work. Hamza Alghabra from DARNA, a local partner of a DEC member, says: “When you hear people say that they would rather die of the virus than fail to go out and provide for their families, it’s devastating.”
To survive, desperate families are going into debt and eating smaller and fewer meals. Around 9.3 million people lack reliable and adequate access to food, the highest number ever registered, and malnutrition is becoming a serious issue with increasing numbers of families relying on food aid.18
A WFP survey reported in November 2020 that half (49%) of families surveyed had lost one or more sources of income because of Covid-19 related restrictions leading to inadequate levels of nutrition.19
The WHO’s Dr Mahmoud Daher says widespread hunger has been staved off in northwest Syria because of the vital work of aid agencies providing food parcels, but this has been made more difficult by border crossings to Turkey being closed, affecting food supplies. “We have to increase our efforts to support the population,” he says.
A ceasefire has been in place since March 2020 in the northwest Syrian province of Idlib, and the WHO’s Dr Mahmoud Daher believes the intensity of the conflict may have been lessened further in recent months due to pre-occupation with Covid-19, helping to reduce the levels of suffering that could have been experienced had war continued to rage. But the conflict continues. Mark Cutts, UN OCHA’s Deputy Regional Humanitarian Coordinator for the Syria Crisis, says: “Shelling has been reported in northwest Syria almost every day since the ceasefire was signed in March 2020 and there have also been airstrikes on some occasions.”
Conflict in Idlib has led to huge displacement, particularly between December 2019 and March 2020 when almost a million people fled their homes. Many of those who were displaced are now sheltering in camps and informal settlements, with limited access to good nutrition and healthcare services, making them even more vulnerable in the context of the ongoing Covid-19 crisis. Overcrowding and poor access to clean water and sanitation increase the risk even further.20 The UN’s Mark Cutts says that many of the displaced people are still sheltering in flood-prone areas and that, during the winter rains, tents are often under water. Conditions are particularly conducive to the spread of the virus, says the DEC’s Response Review, with social distancing “impossible”.
Aid workers say this year’s winter has affected thousands of those living in informal camps with heavy flooding and bitterly low temperatures. The UN reported in late January 2021 how extensive flooding affected 121,000 people in 304 sites with more than 21,700 tents damaged or destroyed. Alexandra Matei from World Vision says: “The winter weather was much worse than we predicted. Every year winter exaggerates the humanitarian needs for all Syrians, but especially for displaced Syrians, and this has been a really tough winter. Right now, it’s minus 3°C, so imagine what that means if you don’t have enough heating, you’re living in a flimsy tent, you have heavy winds and flooding.”
The DEC’s Response Review says that humanitarian funding is already barely able to keep up with ‘normal’ needs despite the allocation of additional pandemic funding.
The WHO and DEC members report that NGOs are having to reprioritise and repurpose existing funds. This has led to tough decisions, including turning people away for food aid if they do not meet certain income criteria, leading to protests from beneficiaries. World Vision’s Alexandra Matei says funding is the biggest challenge the organisation faces, a view echoed by the WHO’s Dr Mahmoud Daher who is concerned about donor fatigue.
The UN’s Mark Cutts says there was an existing funding crisis before Covid-19 and he is concerned about further aid reductions. Last year the UN applied for $3.8 billion in humanitarian aid for the country, including for Covid-19, and received $2.1 billion, or 55%.
This year, the UN will apply for $4.2 billion because of the additional hardships faced but he is not optimistic. In the absence of adequate support, there is always a risk that people will take “desperate measures”, he says, such as child labour and marriage, absence from school, recruitment as fighters and being smuggled across borders to seek refuge in Western Europe. To avoid this, more funding is needed, he says, to ensure that these people can live in safety and with dignity in the region.
“We're about to reach the 10th anniversary of this war. It’s very difficult to sustain the level of funding that is required, year after year for 10 years.
“We're entering a period where the needs have increased, and the available funding is going down. I think it’s going to be very different, very difficult in the months ahead.”
Syria was allocated 16% of the funds available for the first phase of the DEC’s coronavirus response. In the first three months of the response (up to the end of October 2020), six DEC charities – Age International, British Red Cross, CAFOD, CARE International, Oxfam and World Vision – used the majority of funds spent so far (69%) providing water, sanitation and hygiene services, including water trucking and installing handwashing stations, with health projects accounting for 28% of humanitarian relief delivered.
World Vision, for instance, has supported Jisr Al-Shughour hospital in Idlib with running costs, equipment and stipends for staff. It has also provided training for staff in infection prevention and control and Covid-19 case management.
DEC members have provided more than 10,000 health and frontline workers with PPE. Age International has also trained 56 community health workers, including those working in displacement camps, in Covid-19 protection and control, focusing on older people and chronic diseases.
Other examples of aid delivered include the distribution of soap, cloths and buckets to more than 21,000 households in areas where the risk of Covid-19 transmission is considered very high, including camps and crowded urban areas.
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