A few days after Abu Maher was admitted to a hospital in one of Syria’s coastal cities, he felt like he was suffocating.
He had managed to secure the small, private room after exhibiting serious COVID-19 symptoms. After struggling to get out of bed, he made his way to the door, where he cried out for someone to help him.
Not long afterward, Abu Maher (not his real name) was found lying on the floor by the door, unconscious. The oximeter showed that the level of oxygen in his blood was normal, which perplexed a nurse. A doctor who was passing by the room examined it, then told her she’d been using a broken device.
Days later, Abu Maher died in the ICU. He was never tested for COVID-19.
“The hospital does not have enough swabs for every suspected case,” said the doctor who discovered the broken oximeter and whose name we’ve changed to Qusai to protect his identity. “Many recover or pass away because of suspected cases and never get registered.”
Interviews with doctors and the testimonies of patients and residents living in Syria paint a grim picture of a populace, already battered by nine years of war, now struggling to grapple with a pandemic that has cut short many more lives than those disclosed in official statistics.
They say the government has underplayed the extent of the pandemic or failed to respond efficiently because of its underpreparedness. The measures taken to curb the spread of the virus inside the country — such as a partial curfew, a shutdown of schools and businesses for a few weeks, and a ban on gatherings — were limited and easily flouted. Cornered by a collapsing economy, widespread poverty, sanctions, and a shortage of medical supplies and protective equipment after nearly a decade of conflict, Syria appears to be headed into a desultory experiment with herd immunity.
‘What is the point they are trying to make?’
Qusai, a 25-year-old pulmonologist, said he felt relieved when the Syrian Ministry of Health announced on March 22 that it had registered the country’s first COVID-19 case. He and his colleagues had grown increasingly concerned that the government planned to ignore the outbreak even though the virus had already started to circulate within the country.
Qusai’s hopes, however, evaporated a week later when he and his colleagues received instructions from their supervisors not to take swabs from people who they were told “probably just have the flu.” They were also told not to “scare the people of Syria” by suggesting that they might have contracted COVID-19.
Qusai said that friends who were assigned to conduct their postgraduate training in other Syrian governorates told him that they received hints or instructions from their superiors similar to the orders he had received.
“The way the Syrian government is dealing with corona reminds me of those who leave their houses wearing shorts and t-shirts when it is actually freezing outside,” he said. “What is the point they are trying to make? Should everyone give them a round of applause for not having a lot of corona cases? It’s a pandemic that has hit everywhere, even the most stable and developed countries.”
For almost two months after the first case was announced in Syria, official figures showed limited circulation of the virus, with under 50 cases by mid-May. At the time of this writing, that figure had risen to 4,457 cases in territories run by the government, 1,072 in rebel-controlled areas in northwestern Syria, and 1,998 in northeast Syria, where a predominantly Kurdish de facto autonomous administration is in charge. Only 192 deaths have been registered by the Ministry of Health.
The concern that the real scale of the outbreak in the war-weary country exceeds official figures not only persists today but has turned from being the subject of whispers among medical professionals into a full-fledged public panic. Even some officials have ceased pretending that the situation is under control.
“Despite the lack of transparency in the official messaging, I do not think that the government is hiding the real number of COVID-19 cases,” Omar, a doctor in Damascus’ Al-Mujtahid Hospital, said. “The government doesn’t really know how many COVID-19 cases there are, and it does not seem invested in trying to find out.”
Some health officials made attempts at estimating the scale of the outbreak. On Facebook, the deputy head of the Damascus Health Directorate, Ahmad Habas, wrote in the first half of August that there must be at least 112,500 cases in the capital alone. Civil registers showed a hundred people were dying in Damascus every day in the early days of the month, according to Habas, compared to 25 per day during the same period in 2019. There were 75 COVID-19 deaths per day on average, he concluded. Habas later deleted his post.
A study by Britain’s Imperial College estimated that only 1.25% of COVID-19 deaths are being reported in Damascus. It stated that some 4,380 deaths may have been missed by September 2.
In August, an investigation by Syria in Context, an independent outlet, estimated that Damascus alone may harbor 85,000 cases. Satellite images obtained by the outlet showed the rapid expansion of the Najha cemetery in the southern countryside of the capital, where most COVID-19 casualties are buried, according to the Damascus Mortuary Office.
U.N. figures also do not help fill the gaps. In March, the World Health Organization stopped posting the Early Warning, Alert and Response in Emergencies (EWARS) data online. EWARS is a system that helps detect disease outbreaks in conflict zones by identifying health trends, such as publishing how many people were diagnosed with a certain illness in a certain area every week. The absence of this material at the time of the pandemic made it harder to estimate the scale of the outbreak. If 2020 data showed a substantial increase in pneumonia and flu-like disease compared to previous years, for example, that would have been an indicator of the pandemic’s spread in Syria.
Over 200 U.N. staffers and dependents in Syria reported having one or more symptoms of COVID-19, a spokesperson told AFP in September. Of them, 42 staffers and dependents tested positive for the virus.
Multiple doctors across three Syrian governorates who were interviewed for this report said that medical centers are only able to carry out a certain number of tests a day, which might explain why the Ministry of Health sometimes announces almost identical numbers of cases every day. They also said the government has failed to provide enough personal protective equipment for healthcare workers, who have had to buy their equipment on their own – if they can afford it.
The Syrian conflict has taken a massive toll on the system. Between March 2011 and February 2020, at least 595 attacks targeted 350 medical facilities in the country, according to Physicians for Human Rights. The U.S.-based NGO also documented the killing of 923 medical personnel. Moreover, tens of thousands of Syrian doctors have fled the country over the course of the past nine and a half years, seeking refuge abroad.
Qusai is one of thousands of doctors, fresh out of medical school, who constitute the backbone of the war-ravaged Syrian health care system, and who support it through their six-year postgraduate medical training in public hospitals. He did not know that the defining feature of his first months in training would be a struggle at the front line of a global pandemic.
Not only is he worried about the medical sector’s inability to treat all those who are infected, but he also fears for his own health and for that of his colleagues. A list bearing the names of 61 health care workers who died of COVID-19 in Syria circulated on social media in August. The death of five doctors and one pharmacist in Aleppo on the same day, Aug. 14, sparked an uproar among residents.
An outbreak in Damascus’ Al-Assad University Hospital landed even its director-general in the ICU in August, according to a statement published by the hospital’s administration. A month later, Mohammad Makhlouf, father of businessman Rami Makhlouf and the man who built the Assad family’s financial and business empires during the era of Hafez al-Assad, died of COVID-19 in that same hospital.
In addition, many Syrians refrain from going to a hospital when they suspect that they might have the virus. Tales abound of preferential treatment for those affiliated with the army and security services, as well as pictures and videos showing how crowded and chaotic medical centers are, with one doctor in a WhatsApp message that went viral describing it as akin to “Judgment Day.”
Ahmad Rafea, a well-known actor who was taken to a hospital in Damascus when he was suspected of having COVID-19, said in a radio interview, “I went and saw dozens of people in front of me, all of them sick, some of them [lying] on the floor. Do you know how many deaths I witnessed in one day? Sixty deaths.”
Rafea also said that there are no oxygen tanks in hospitals for patients who are suffocating because of their infections. Others reported that oxygen is disappearing from Syrian markets because of the number of people using it to treat themselves at home.
“Ironically, the two kinds of places where one is most likely to contract corona are hospitals and PCR testing centers,” said Hanan Ades, a schoolteacher in Damascus. “If I or one of my family members start to lose the sense of smell or manifest any other corona symptoms, we’re probably going to treat that at home.”
Ades, a teacher who went back to school in mid-September, is one of thousands of Syrians who called for a delay to the 2020-2021 school year. The Ministry of Education, however, insisted on reopening schools on time.
“I almost think that the government is letting the pandemic get out of hand in order to reduce the population because it can no longer provide for it,” said one restaurant owner in Aleppo.
Even though there is no evidence the government is deliberately adopting such a strategy, it illustrates what many residents of Syria, even ones who support the government, have been reduced to believing as panic spreads.
In addition to limited testing capacity, the accuracy of tests administered by the government has been called into question. After obtaining negative PCR test results in Damascus, a delegation flew from the capital to Geneva in August in order to participate in U.N.-sponsored negotiations. On the first day, on Aug. 24, the session was put on hold because at least four of those who came from Damascus tested positive for COVID-19 after they arrived in Switzerland.
Syria began introducing drastic lockdown measures in mid-March, before any case was registered in the country. Educational institutions were shut down; cafes, restaurants, pubs, and venues for public gathering were closed; and collective prayers were banned. Later that month, Syria imposed a partial curfew, from 6 p.m. to 6 a.m. every day, and banned movement from one governorate to another.
The measures, however, were not strictly adhered to. People were reportedly able to pay their way out of a penalty for breaking the curfew, while others bribed police at checkpoints in order to be able to travel between different provinces. By the time the number of cases skyrocketed, almost all measures had been removed. Despite the financial strain, calls have been growing online in recent weeks for the measures to be reintroduced and strictly upheld until the outbreak is contained.
In quarantine centers, which housed suspected domestic COVID-19 cases as well as ones coming from abroad including hundreds of repatriated citizens, people were jammed together in small rooms and forced to share unsanitary utilities. Karam, an administrative assistant at a cash transfer agency, was taken to a center in the Damascus countryside upon his return from Baghdad, where he had to sleep on unwashed sheets and pillowcases.
“It was a nightmare. I got out of that place 14 days later with a negative test result, only to go seek out another test because I was certain that I contracted the virus in that place,” Karam said.
One symptomatic person who was taken to a quarantine center reportedly made a phone call to his relative, a general, who came and scolded the medical team. “Shame on you,” he said. “This man has a brother who died fighting for our country; he comes from a patriotic family who gave so much for our homeland, and you accuse him of having corona.”
A doctor in Latakia reported that many Syrians are ashamed of admitting that they have COVID-19 symptoms, and do not want to be ostracized.
“I have had to ask the same question in many different ways in order to get straight answers from people who treat having corona like having an STD,” he said.
Not long after measures were eased, pictures of huge crowds and gatherings started to circulate on social media. Footage showed hundreds of soccer fans in Latakia celebrating the victory of their local team, while others showed young men and women attending a beach party in the coastal city of Tartus in August. Candidates running in parliamentary elections, which took place July 19, did not enforce any preventive measures in the dozens of receptions and social events they held for their prospective voters.
Many Syrians have adopted the attitude that, because they survived years of brutal civil war, they shouldn’t worry too much about the coronavirus. Others espouse conspiracy theories that originated in the West, such as the idea that the global lockdowns were instituted to facilitate 5G installation. Some conspiracy theories were spread by official channels. A state-run radio station reported that people should not worry about the virus because it loses potency in the Middle East’s hot climate.
The crisis is also unfolding in areas outside the government’s control. An outbreak in the Kurdish-controlled northeastern region has been fueled by dozens of illegal crossings into the area and by infected people arriving through the local airport in Qamishli. Testing rates remain low.
In Idlib in the northwest, where Turkey-backed opposition forces hold sway, the outbreak continues to grow, albeit at a slower pace. The northwest is home to vulnerable populations of internal refugees who cannot adhere to social distancing or adequate handwashing in crowded camps. The region has also lost many of its medical centers and health care workers due to Russian and Syrian regime airstrikes over the past few years.
Even as the pandemic accelerates, Syrian state media is downplaying the impact of the virus, claiming that it is losing potency and that the outbreak is winding down. The official news agency SANA interviewed health officials who said there are fewer deaths and fewer serious cases now. Such claims are not backed by independent medical research or available data. Medical professionals who were interviewed for this report do not believe that the country’s worst days are behind it.
“We would be thrilled to see this outbreak fade out, but that does not mean that we should say so when it clearly isn’t,” said Qusai, the doctor. “In Syria, we have been hit hard with this virus because of our underpreparedness, and now that the schools have reopened and summer is coming to an end, I can only imagine that the situation will deteriorate.”