Northeast Syria has been affected by the pandemic. More than 700,000 people have been displaced from their homes in the region, most of them depend almost entirely on humanitarian assistance. They are spread across the provinces of Raqqa, Hassakeh and Deir ez-Zor, as well as around the city of Kobanê / Ayn Al-Arab in the eastern province of Aleppo. Many live in overcrowded environments, including official camps, informal camps, and makeshift settlements in schools and markets. Tens of thousands more live in the homes of local residents.
Like much of Syria, this area has been devastated by more than nine years of conflict. The most recent incident of insecurity was in October 2019, when a Turkish-backed military operation was carried out in the north. The fighting caused further displacement and further destroyed the fragile infrastructure of the region. In addition, much-needed humanitarian aid was withdrawn. Doctors Without Borders (MSF) had to reduce its activities for several months. Today, many medical facilities are no longer operational and those that remain open struggle to respond to people’s needs.
What about the water supply
There is currently a great crisis with water. The Al Halouk station serves some 480,000 people in Hassakeh province, including those in Al-Hol and other camps for displaced people. It was seriously damaged last October, cutting off the supply of water to the entire region. Although it has since been fixed, supplies have been disconnected and interrupted throughout 2020. Widespread shortages over the past two weeks have sparked protests and riots.
We cannot access Al Halouk at the moment, so we are supporting the local authorities with a recently installed water station called Al Himme, north of the city of Hassakeh. We are donating the laboratory equipment and chemicals needed to treat it so that it can be safely drunk and distributed. When fully operational, it is estimated that Al Himme can supply a maximum of 30% of the area’s water needs. We are concerned that there may be serious consequences for public health. Access to drinking water is essential in any emergency situation; the shortage could spell disaster for covid-19.
What is happening with COVID-19?
There is no doubt that we are seeing increases in covid-19 cases in northeast Syria. As of September 18, there were 1,121 confirmed cases, one sixth of them among health workers. The tests are limited, but of the tests carried out, almost half are positive. This suggests that transmission rates are high and much more are needed.
Until a month ago, the cities of Hassakeh and Qamishli were the main contagion points (264 and 358 confirmed cases to date in both cities) and there had not been too many cases in larger population centers. However, right now the situation is much more worrisome, as there is already community transmission in the city of Raqqa, a densely populated area that is home to large numbers of displaced people and is still recovering from the destruction of the war. The same is true in the rest of the governorates of northeastern Syria. In these places, insufficient diagnostic tests are being carried out, health services are scarce, and access to water and sanitation is poor.
Few hospital beds are available for isolation or intensive care in the region. As Covid-19 spreads, various local governments and humanitarian agencies have plans to provide more beds in different locations.
Working with the Kurdish Red Crescent, MSF is supporting the only hospital dedicated to covid-19 in northeastern Syria, outside Hassakeh. It has a total of 100 beds dedicated to covid-19 patients and an area specifically designated for suspects. The hospital also has an intensive care section. As part of the humanitarian working group to respond to covid-19, chaired by local health authorities, we have also provided training throughout the region and helped renovate a 48-bed isolation ward at Hassakeh National Hospital, the hospital. largest general in the region.
What is the impact of covid-19 on healthcare workers?
We are particularly concerned about the high rate of infections among healthcare workers. First, of course, is the impact on them and their families. Then we see a knock-on effect to an extremely fragile healthcare system. Not only can these personnel not work, but the rest, who were in contact with them, must also be quarantined. The result is that medical facilities with already limited services have often had to close completely. In some places, these employees report that they are too scared to go to work.
Until recently, most of them worked in different facilities in northeast Syria. Of the health personnel who tested positive for COVID-19, most had previously been in public health services and with humanitarian agencies, including clinics in camps like Al-Hol. In response to rising infection rates, local authorities have introduced new regulations that prohibit staff from working in more than one health center.
This is the field of Al-Hol
The Al-Hol camp in Hassakeh province, near the Iraqi border, is the largest in northeastern Syria. Today, some 65,400 people are detained there, most since the final battles between the Islamic State (IS) and the Syrian Democratic Forces in early 2019. More than 90% of the residents are women and children; two thirds, under 18 years of age.
Restrictions on the movement of people, which were already strict before covid-19, have been further tightened as a result of the pandemic
Al Hol is a closed field, which means that you cannot enter and exit freely. Surrounded by barbed wire, the place is very safe and its entrances are heavily guarded by security forces. It is extremely overcrowded; on average seven people live for each tent (modest in size), in some places, several families huddle together in common spaces. Movement restrictions, which were already strict before covid-19, have been further tightened as a result of the pandemic. For many it is impossible to leave the field, even for short periods of time.
Most of the inhabitants, those of Syrian or Iraqi origin, live in the main camp. Then there is the Annexed. In this separate and even safer area, about 10,000 citizens of “third countries” languish, completely neglected by the world. Some governments and humanitarian agencies have been reluctant to provide services in the Annex because of the perceived affiliations of those there.
Health care in Al-Hol
At the moment, there is almost no medical care available, as many health facilities have closed as a result of the side effects of COVID-19. The consequences are devastating. In just one week in August, seven children died, all under the age of five. We hear horrible reports of their mothers going from one clinic to another in a desperate search for someplace that is open.
In May there were 24 primary care clinics in the field; at the beginning of August there were 15. Currently, five of them are open, including the MSF clinic in the Annex. Since we were able to reopen it at the end of July, we have treated more than 1,000 patients.
In the whole field we also carry out a project to provide wound treatment, visiting the tents, for people who cannot reach the clinics. There are three field hospitals, but none are currently fully operational. Until last week there was no emergency medical care available at the main camp. Fortunately, some limited services have been able to restart. But it is not clear how long this can be sustained, given the high rates of contagion among health personnel.
Referrals for more critical cases are possible, but can be complicated and time-consuming to organize. And as COVID-19 impacts healthcare across the region, referral options are likely to be reduced.
There is an ongoing outbreak of diarrhea, young children are particularly vulnerable. As a result, many suffer from malnutrition. In our therapeutic feeding centers, about 80% of our patients under the age of five have acute diarrhea. Admissions to our inpatient therapeutic feeding center increased 71% in July, and we cared for 157 malnourished children as outpatients.
Clean water and hygiene are top priorities, especially in the scorching summer heat. In July, we delivered 15.2 million liters of chlorinated water and treated another 69.3 million liters for others to distribute.
Covid-19 in Al-Hol
A month ago we heard of the first confirmed case of covid-19 among the residents of Al-Hol. As of today, there are already three. We are concerned about what will happen next. Al-Hol is not well prepared for an outbreak. An isolation facility has been built but is not ready for use. It does not have enough trained personnel and lacks basic water and hygiene infrastructure and adequate infection prevention and control measures. There are also problems with medications and medical equipment, including oxygen support. It is not surprising that when people with suspected COVID-19 were identified in the field, they were reluctant to go there.
Our teams have identified 1,900 people throughout the camp who are particularly vulnerable to covid-19, many of whom have non-communicable diseases, such as diabetes, hypertension, asthma or heart conditions. We are doing our best to provide them with the medications they need, as well as soap and other essentials. This is especially important since they cannot go out and buy them themselves.
MSF has been working to provide specific health awareness messages on how to stop the spread of covid-19, but it is challenging to ask people who live close together to take impossible measures, such as physical distancing.
There is an ongoing outbreak of diarrhea, young children are particularly vulnerable. As a result, many suffer from malnutrition
There should be more humanitarian assistance. This requires a collective effort. As MSF, we are trying to meet the needs of as many people as we can and to support the work of other organizations. But much more attention and commitment is needed; areas like the Annex have been practically abandoned by the world. Regardless of people’s perceived affiliation, access to medical and humanitarian assistance are basic rights.
In addition to our work in Al-Hol and the broader response to COVID-19 in Northeast Syria, we continue to support free access to primary and secondary healthcare in Raqqa and vaccination activities in Kobane / Ayn Al Arab. We also continue to assess the health and humanitarian needs of people living in remote areas, socially or economically excluded, informal settlements and other fields.
Will turner is MSF’s emergency manager for Syria.