Russia and the Syrian government are intensifying a bombing campaign in Idlib that is straining a health sector already overwhelmed by the Delta variant of the coronavirus.
On Sunday, air strikes killed at least 12 civilians and five fighters belonging to the Turkish-backed Free Syrian Army, who are among the remnants of the armed opposition active in the north of the country.
Almost daily artillery and air bombardments could foreshadow worse days to come.
Syrian President Bashar Al Assad has long stated his ambition to re-take remaining rebel-held territory.
Idlib's forever war
Three years have passed since the Syrian government, Russia and Turkey agreed on “demilitarising” the northern region.
But the truce broke down within days and Idlib has remained in a state of semi-permanent war ever since.
The increase in air strikes has brought back memories of the worst period of the war for many health workers.
In mid-2019, Syrian government forces, backed by Russian air power, pushed into the province in an ill-fated offensive.
Their gains were slim, but hundreds of medical centres were put out of service and hundreds of medical personnel were killed or injured. According to the International Rescue Committee NGO, by 2020, 80 per cent of healthcare workers in Idlib knew at least one person or patient killed in an air strike.
That has worsened a shortage of staff and by the start of last year, the World Health Organisation said at least 70 per cent of medical workers had left the country.
On a single day in February 2019, air strikes hit three hospitals in Idlib, killing or injuring 200 people, according to Doctors Without Borders.
The WHO has documented 337 attacks on medical centres in north-west Syria between 2016 and 2019.
In mid-March 2020, the WHO said that out of 550 medical facilities in the region, half of them were out of service.
Human Rights Watch has said that the Syrian and Russian attacks on civilian infrastructure in north-west Syria could be crimes against humanity.
Demilitarised zone
A period of relative calm earlier this year was cruelly deceiving; university students went back to class, with many pursuing medical careers in what some Syrians refer to as “the free north”.
The number of military attacks hitting hospitals has decreased but Covid-19 is creating war-like conditions in some wards, said Fuad Al Absi, a general doctor working at a hospital in Idlib city sponsored by Sema, the Syrian Expatriate Medical Association.
“Throughout the bombing, we used to witness significant damage to buildings and physical injuries," Dr Al Absi said. "But this wasn’t as mentally tiring as the look of weakness and misery we saw in the eyes of people with disabilities.”
Then, early last year, Covid-19 struck.
At the time, NGOs said that the medical sector could collapse, but now medical workers face the risk of infection.
The number of confirmed Covid-19 cases in northern Syria has exceeded 28,500 since last August, according to Syrian response co-ordinators. But the rate of testing is considered to be inadequate and the real number of cases is thought to be at least 10 times higher.
Hospitals and intensive care wards are full.
“We can’t receive a new patient, even if the case is critical,” Dr Al Absi said.
“Covid is back nowadays to remind people of the miseries they lived in, putting them face-to-face with continuous catastrophe. There's no way to avoid Covid due to the crowded conditions the people face, and the spread of refugee camps in the region."
Despite suffering occasional, heavy bombardments during Syria’s 10-year conflict, Idlib has become known partly as a refuge and partly as an area where the regime would send “surrendered” combatants, returned in deals with rebel groups.
The governorate’s increased population of more than three million people – about two million of whom are internally displaced – is a result of the conflict.
Aid shortage
In these crowded conditions and sprawling refugee camps, Covid has become a silent killer.
According to Idlib Health Directorate, deaths have surpassed 1,000 and are increasing daily by tens of people.
“Due to the hospitals being unable to contain the situation, we have 1,000 cases of coronavirus; 150 of them require beds and respiratory devices,” Dr Al Absi says.
“Entire countries cannot provide these requirements.”
That may sound like an exaggeration, but before the Covid-19 crisis, Ireland – which has a population about two million more than Idlib – said there were 225 critical care beds available in the country, according to the Irish Health Service Executive.
In other words, most countries are desperately trying to expand their own capacity before much help can be sent abroad.
In the absence of enough beds, the doctor advises sticking to basic health precautions like social distancing and hand washing and, where possible, getting vaccinated.
The Syria Response Co-ordinators Team, an NGO, is using Facebook to call on anyone with medical knowledge to help stop “the catastrophe” because health workers are exhausted. The epidemic “is now in the critical stage,” they warn.
“I know that preventing the disease is much better than a thousand cures – and it’s being warned about in mosques, health centres and public markets. But we also have to live,” said Akram Haj Assaf, 60, a vegetable seller.
“Rising living expenses have their own role in spreading the virus. The economic situation prevents poor people like me from staying indoors because we depend on our daily salary to provide for our families and children and to pay the rent. The day we don’t work is the day we have no food and wait for God’s mercy."
