Idlib cannot be left alone to deal with Covid-19

The effects of an outbreak in the impoverished, rebel-held province of Syria could be devastating

A mask-clad civil society volunteer marches with an effigy depicting the SARS-CoV-2 virion, the agent responsible for the COVID-19 coronavirus disease, during an awareness campaign about the novel coronavirus pandemic, urging people to remain at home, in Syria's northwestern city of Idlib in Idlib province on March 24, 2020. (Photo by Abdulaziz KETAZ / AFP)

Syrian Kurdish passengers who were stranded in Damascus arrive in Qamishli in Syria's northeastern Hasakeh province on April 5, 2020, after being stranded in Damascus for the past weeks. (Photo by DELIL SOULEIMAN / AFP)

A drone image taken on April 9, 2020, shows a sanitation worker disinfecting a camp for displaced Syrians next to the Idlib municipal stadium in the northwestern Syrian city, during a campaign to limit the spread of the coronavirus (COVID-19) pandemic. (Photo by OMAR HAJ KADOUR / AFP)

A medic checks the body temperature of young passengers, as a preventive measure against the coronavirus, upon their arrival by bus in Syria's Kurdish area from Iraqi Kurdistan via the Semalka border crossing in northeastern Syria on February 26, 2020. (Photo by Delil SOULEIMAN / AFP)

A picture taken on April 27, 2020 shows Syrians who returned from Turkey standing at a quarantine facility in the countryside of the town of Jisr al-Shughur, west of the mostly rebel-held Syrian province of Idlib, on April 27, 2020 during the coronavirus COVID-19 pandemic. / AFP / Abdulaziz KETAZ

epa08392436 A truck for prevention against the COVID-19 coronavirus disease, operated by local NGO 'Violet Organization', drives through the streets of Idlib, Syria, 29 April 2020. EPA/YAHYA NEMAH

Artist Aziz al-Asmar paints a mural wishing for the well-being of German Chancellor Angela Merkel, who is in quarantine after being treated by a doctor who tested positive for coronavirus (COVID-19), inside a damaged building in the town of Binnish in Syria's northwestern Idlib province on March 24, 2020. (Photo by Muhammad HAJ KADOUR / AFP)

A member of the Kurdish Internal Security Forces of Asayesh urges children to return home, in Syria's northeastern city of Hasakeh on April 30, 2020, following measures taken by the Kurdish-led local authorities there, to limit the spread of the novel coronavirus. / AFP / DELIL SOULEIMAN

Syrian boys pose for a picture during an awareness workshop on Coronavirus (COVID-19) held by Doctor Ali Ghazal at a camp for displaced people in Atme town in Syria's northwestern Idlib province, near the border with Turkey, on March 14, 2020. (Photo by AAREF WATAD / AFP)

A handout picture released by the official Syrian Arab News Agency (SANA) on March 20, 2020 shows Syrian Red Crescent vehicles spraying disinfectant along a street in the capital Damascus, as part of measures against the spread of COVID-19 coronavirus disease. (Photo by - / SANA / AFP) / == RESTRICTED TO EDITORIAL USE - MANDATORY CREDIT "AFP PHOTO / HO / SANA" - NO MARKETING NO ADVERTISING CAMPAIGNS - DISTRIBUTED AS A SERVICE TO CLIENTS ==

A volunteer from the Violet organisation disinfects a mosque in Syria's northwestern city of Idlib on April 25, 2020, from coronavirus (COVID-19) during the Muslim holy fasting month of Ramadan. (Photo by OMAR HAJ KADOUR / AFP)

Only a few people walk in the century-old covered bazaar of Hamidiya in Syria's capital Damascus on March 24, 2020, after measures were taken by the authorities to fight the novel coronavirus pandemic. - Across much of the Syrian capital, with squares and markets once thronging with people even during the war, are now almost entirely empty. Five cases of COVID-19 have been reported in the country since Sunday, and the authorities have ordered all non-essential businesses closed. (Photo by LOUAI BESHARA / AFP)

Researchers are examining the possibility of using inhalers to introduce stem cells into a patients lungs. AFP

A member of the Syrian Violet NGO disinfects a triage tent erected for suspected coronavirus patients outside the Ibn Sina Hospital in Syria's northwestern Idlib city on March 19, 2020. - Syrian authorities on March 13 announced measures aimed at preventing coronavirus from reaching the war-torn country, including school closures and a ban on smoking shisha in cafes, state media reported. (Photo by Abdulaziz KETAZ / AFP)

A young pupil follows a lesson on a mobile telephone inside a tent, in a camp for displaced Syrians in the village of Kafr Yahmoul in the northwestern Idlib province, amid the coronavirus pandemic on April 3, 2020. - Like in much of the world, educators in Syria are taking classes online after the country's various regions sent pupils home hoping to stem the COVID-19 pandemic. But distance learning is no small feat in a country battered by nine years of war, where fighting has displaced millions and the electricity supply is sporadic at best. (Photo by Aref TAMMAWI / AFP)

It was always a matter of time. Late last week, the first coronavirus case was discovered in Idlib, a province in Syria bordering Turkey where hundreds of thousands are living in crowded refugee camps after fleeing war. Without urgent measures to contain any potential outbreak, it could spell disaster for one of the most vulnerable communities in the world.

News of the first infection emerged last Thursday, and by Tuesday the number of confirmed cases had risen to four, including two in Idlib and two in opposition areas in rural Aleppo. All, according to the UN’s Office for the Co-ordination of Humanitarian Affairs (OCHA), are healthcare workers, which means it is likely that they were in contact with patients who visited their clinics or hospitals. They are all currently in isolation and contact tracing is under way to see who else may be infected.

Aid workers have long warned of the dangers of an outbreak in a place like Idlib and the devastating effects it could have. To understand the risks, we need to take a step back and examine the situation as a whole.

Idlib is one of the last remaining areas outside the Syrian government’s control after nine years of attempted revolution and civil war. It is under the control of armed groups, some of whom used to be affiliated to Al Qaeda but severed ties a few years ago. The province, which is in north-western Syria, is home to about 4.1 million people, including 2.7 million who were displaced during the war and who need humanitarian assistance, and most of whom are women and children.

A ceasefire has been in place in Idlib since March. But before that, the civilian population endured the full brutality of the Syrian government and its allies, from unrelenting air strikes to chemical weapon attacks and the bombing of hospitals, schools and refugee camps. When loyalist soldiers reclaimed parts of Idlib earlier this year, some of them dug up and desecrated bodies of the dead in local cemeteries.

Almost 800,000 people fled the fighting in Idlib between December and March, and the vast majority of them still live in crowded tents near the border because they are too afraid of returning to their homes only for the fighting to erupt again. It is horrifying to contemplate the possibility of an outbreak in one of those camps, with the lack of water and crowded conditions making practices such as social distancing and frequent handwashing and sanitising a pipe dream.

Idlib is also in a poor position to grapple with a public health crisis. The Assad regime has systematically bombed hundreds of healthcare facilities in areas controlled by the opposition, and this has left few hospitals and clinics able to deal with an outbreak. Another seven hospitals have suspended routine operations to limit the spread of the virus in medical facilities.

Instead of making it easier for aid agencies to send medicine and testing kits across the border to arrest the spread of the pandemic in these impoverished areas of Syria, both Russia and China held up the renewal of a UN mandate to deliver cross-border aid, finally agreeing to a last-minute deal that saw the closure of one of the two remaining border crossings through which humanitarian aid flows from Turkey into the rebel-controlled parts of the country.

Idlib and its environs are not the only vulnerable areas in Syria. The country as a whole is beaten down by nine years of conflict followed by a grave economic crisis that is threatening the food security of citizens. The Syrian pound has collapsed, making even basic staples too expensive for many families, and poverty and unemployment are rampant with no reconstruction aid expected any time soon. The recent Caesar sanctions imposed by the US against the regime will choke off any remaining lifelines.

As of Tuesday, the Syrian Ministry of Health had confirmed 417 cases of Covid-19, including 19 deaths and 136 recoveries, with the majority being in Damascus and its countryside. There are also cases in the Kurdish-controlled north-east. The mix of restrictions on movement and economic activity that were briefly imposed has cost many people their livelihoods, while the recent lifting of these restrictions is likely to contribute to the spread of the coronavirus. Neither is a scenario that Syria can afford.

But these challenges are even more severe in the displaced and destroyed communities of Idlib. The collapse of the economy and possible coronavirus-related restrictions are going to be much worse for families that have been displaced many times over the course of the war, forced repeatedly to move and find shelter, leaving their lives behind, and for families that overwhelmingly rely on humanitarian aid for food, education and healthcare. Nearly three in every 10 children under five in north-western Syria are stunted because they are chronically underfed.

Lockdowns to combat the spread of infection are likely to have an outsized effect on their livelihoods and make it harder to deliver desperately needed assistance.

They have also had deeply troubling effects on women and children. OCHA says that domestic violence and sexual abuse are on the rise, as are practices such as child labour, early marriage, forced abortion and forced prostitution that bring in some financial relief for desperate families.

So far, just 2,500 Covid-19 tests have been administered in opposition areas. Throughout the country, only 12,000 tests have been administered, which means we have little grasp of the real scale of the pandemic in Syria.

Other countries in the region, including Egypt and Iran, are buckling under the strain of second waves of the coronavirus, unable to control a raging pandemic. Neither country is at war. Outbreaks of such magnitude will be far more devastating in Syria, and we must break the cycle of catastrophes.

Kareem Shaheen is a former Middle East correspondent based in Canada