Covid-19: Compounding 10 Years of Health Crises in Syria

The Path Forward is a CSIS Humanitarian Agenda series of reflections from humanitarian organizations on the challenges in food security, disrupted health systems, humanitarian access, civilian protection, and, ultimately, recovery for the Syrian people.

March signifies one year since the first case of Covid-19 was confirmed in Syria. Just as the pandemic shook the world, it has had deadly effects across Syria. In the northwest, cases quadrupled between November and December in flood-affected camps for internally displaced persons (IDPs). In the northeast, cases rose by a record 1,000 percent in August. In government-held areas, local doctors describe overwhelmed hospitals forced to turn patients away. The pandemic is compounding a dire humanitarian situation. Its impact cannot be analyzed in a vacuum but rather must be seen in the context of a decade of health crises, a destroyed health system, and a deeply vulnerable population.

A Broken Health System

Violence against healthcare workers has been at the heart of the conflict in Syria, splintering the health system and devastating entire communities. Since the beginning of the conflict in 2011, there have been at least 595 documented attacks on health facilities in Syria, a pattern of war crimes that continue with impunity. According to Physicians for Human Rights, over 90 percent of the attacks have been perpetrated by the government of Syria and its allies. Over 70 percent of health workers have fled the country, adding an additional burden on those who remain.

The healthcare system is also fractured: it has become decentralized, with local health directorates playing the role of the Ministry of Health in non-government-held areas but without the resources or protection to actually do so. This decentralization, though born out of necessity, has created gaps in coordination and information sharing, including with parallel disease surveillance systems that are vital early-warning alerts for outbreaks such as Covid-19.

A Decade of Health Crises

Even before the Covid-19 pandemic, the shattered health infrastructure in Syria was unable to cope with the scale of health emergencies. Infectious diseases such as polio and cholera, alongside chronic ones such as diabetes, have wreaked havoc on communities. Health providers struggle with both adequate service provision (e.g., vaccines) and in addressing underlying social determinants, such as overcrowded living conditions and a general loss of social support structures, particularly for women and children. Reports of violence against women during Covid-19, coined “shadow pandemics,” and unprecedented rates of malnutrition in Syrian children demonstrate the compounded fragility of communities in crisis.

The Impact of Covid-19

The true scope of the Covid-19 outbreak in Syria is unknown due to limited testing capacity, underreporting, lack of access to healthcare, and stigmas associated with the virus. There have been 14,048 Covid-19 cases reported by the Ministry of Health in government-held areas, 8,447 cases reported in the northeast, and 21,032 cases reported in the northwest. However, these numbers are likely underestimates.

In government-held areas, local hospitals report running out of body bags, and health officials believe that reported Covid-19 cases are only a fraction of the real number. Across northern Syria, destruction of water and sanitation systems has hindered preventive measures for Covid-19, and social distancing has proven infeasible in densely populated camps. For 4 million people in northwest Syria, half of whom are IDPs, there are only 212 ICU beds for Covid-19 patients. Across the country, there is a dire lack of personal protective equipment, reliable oxygen, and ventilators. While NGOs are stepping in to fill these gaps, such as Syria Relief & Development’s infection, prevention, and control measures under the Covid-19 emergency task-force and MedGlobal’s initiative building oxygen generator stations, they cannot fulfill the population's needs alone.

The decentralized health response creates critical challenges for a Covid-19 vaccination campaign. Syria’s Ministry of Health is expected to receive the vaccine for free through COVAX in April, though the World Health Organization (WHO) indicates that the initial rollout may only cover 3 percent of the population. However, there are still unanswered questions around which areas will be included in the national vaccination plan, particularly the northeast. In the northwest, the Syria Immunization Group has separately requested vaccine procurement through COVAX, with plans to implement a cross-border response. But even if vaccines are procured and accessible, Syria lacks the necessary equipment and reliable electricity to properly handle and store certain coronavirus vaccines. Beyond logistical barriers, it is critical to address growing misinformation and stigma associated with Covid-19 to implement an effective vaccination campaign.

Equity, Access, and Locally Led Solutions

With the new U.S. administration emphasizing a foreign policy reset, it is particularly important to ensure a global health policy that centers around the principle of health equity. Close coordination with the WHO is needed to increase access to vaccines through COVAX for vulnerable populations in conflict zones such as Syria. The United States and other UN member states should ensure that vaccination supplies provided through the WHO are independently monitored and equitably distributed.

Humanitarian assistance and healthcare have long been denied to Syrians as a tool of war, through lack of access, prevention of cross-line aid delivery, and removal of medical supplies—including vaccinations—from aid convoys. The UN Security Council resolution ensuring cross-border humanitarian access into Syria—already reduced to one border crossing in 2020—is up for renewal this July. It is critical that the Security Council renew cross-border access for a minimum of 12 months. The Biden administration should work with the United Nations and donor governments to ensure an ongoing cross-border aid mechanism to provide life-saving assistance, including coronavirus vaccines, to the millions in need.

Over the last 10 years, Syrian NGOs and civil society organizations have been the leaders of the humanitarian response, taking on immense personal risk to serve communities. They can lead the campaigns on the ground but require the assistance of governments to negotiate their safety and provide support. As the largest donor government to the Syria crisis response, the Biden administration has a critical opportunity to reassert the United States’ role as a global and innovative humanitarian leader by increasing flexible funding to Syrian NGOs, allowing them to adapt to an ever-changing context and meet the health needs of their communities.

Amany Qaddour is the regional director of Syria Relief & Development and a DrPH student and associate at the Johns Hopkins Bloomberg School of Public Health. Kat Fallon is the director of policy at MedGlobal, a humanitarian health NGO.

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