Syria’s Idlib was already a humanitarian nightmare. Now the coronavirus has arrived.

Last week, a doctor in his 30s working at a hospital in Syria near the Turkish border tested positive for Covid-19. Three more confirmed cases came after: two doctors and a nurse. The coronavirus had officially arrived in Idlib, the last rebel-held territory in Syria.

The outbreak threatens to exacerbate the ever-present humanitarian disaster in northwest Syria. The United Nations estimates about 4 million people now live in the region, almost half of whom have fled from other parts of the country, displaced, sometimes more than once, during the nine-year civil war.

“After nine years of conflict and the targeting of hospitals and medical staff, the medical system, particularly in the northwest, is on its knees,” Vanessa Jackson, the United Nations representative for the humanitarian aid agency CARE International, told me. “There really aren’t enough doctors and health care professionals available if there is a significant outbreak, let alone access to ICUs, let alone to ventilators, PPE [personal protective equipment].

“You name it,” she added, “they do not have it.”

As of July, approximately 11 people have tested positive in northwest Syria, in Idlib and Aleppo, according to the Syrian Observatory for Human Rights. At least six were health care workers.

It was always a matter of time before the coronavirus crept into Idlib. And while these past few days saw the first confirmed Covid-19 cases, it does not mean they are the first infections. The question now is whether the virus can be contained, and what that might mean for the millions of civilians in the region.

Renewed fears about the spread of the coronavirus also come as a vital United Nations humanitarian aid route into northwest Syria has been cut off following a UN Security Council vote. Russia, which backs Syrian President Bashar al-Assad and has veto power on the UNSC, wanted to shut off the route. That leaves just one available crossing for the United Nations to provide critical aid — food, medical supplies, and everything else — into the northwest.

This puts Idlib, and northwestern Syria more generally, in an even more precarious position, with the possibility of the pandemic spiking against the backdrop of food insecurity, a collapsing Syrian economy, and the threat of violence.

Omar Al-Hiraki, a surgeon at the Bab Al-Hawa Hospital in northwestern Syria, is currently in Turkey, but he told me via WhatsApp that he’s been in touch with his staff and his hospital, where the first coronavirus case in Idlib was detected. He told me he’s unsure “how to deal with this dire situation, without equipment, without enough testing.”

“When we look at the United States and the UK — it’s chaotic what happened,” he said. “How can you imagine what can happen in northwest Syria?”

Idlib’s health care system was already strapped. Then the coronavirus threat came.

Earlier this year, Assad, backed by Russia and Iran, waged a bloody campaign to retake Idlib, the last remaining opposition stronghold, as the dictator sought to consolidate control over the country. The United Nations has accused the regime of committing war crimes during its assault, including attacks targeting hospitals and schools.

That fighting threatened to unleash the worst humanitarian catastrophe in almost a decade of war. It forced approximately 1 million people to flee deeper into Idlib in a matter of months, pushing civilians into a smaller area closer to the Turkish border. According to the UN, almost 80 percent of the newly displaced were women and children.

Then in March, Turkey, which backs the anti-regime rebels, launched an offensive into Idlib, saying it was doing so “to stop the Syrian regime’s massacres” and to prevent the continued displacement of civilians. But another reason for the offensive, experts say, was that Turkey, which already hosts about 4 million Syrian refugees, did not want to see tens of thousands more people flood over the border into the country.

Turkey’s intervention increased the chances of direct confrontation with Russia, with millions of civilians potentially caught in a crossfire. Ultimately, Moscow and Ankara brokered a ceasefire agreement in early March. The deal was shaky and imperfect, but it has largely held, averting the worst of the violence for months.

This left Idlib in a precarious limbo. Only about 100,000 displaced people — of the nearly million who fled from December to early March — have returned to their homes. Tens of thousands still live in makeshift housing or congested encampments, with limited access to water and sanitation.

“There are basic services but they’re of varying quality,” Paul Spiegel, director of the center for humanitarian health at the Johns Hopkins Bloomberg School of Public Health, told me. “You’ve got poor water, sanitation, increased congestion. All of these are very good conditions, unfortunately, for the virus to spread.”

In March, just as the pandemic was spreading worldwide, a report by CARE International surveyed 78 camps housing internally displaced people in northwest Syria; of those, 91 percent did not have access to soap, and 83 percent did not have any place for people to wash their hands. Water was scarce, and almost 45 percent reported not having enough to last 30 days.

“And, of course, people are living in very cramped conditions,” Kieren Barnes, Syria country director at Mercy Corps, told me. “There’s not a lot of social distancing. That’s not very easy to do in an informal camp setting, or in the community. So if [the coronavirus] were to catch,” he said, “it would be quite devastating.”

The health care system in northwest Syria was already under strain even before the threat of the coronavirus emerged, starved for resources and worn thin from the Syrian government’s assault. Russia, Assad’s benefactor, targeted hospitals and health care facilities in its indiscriminate bombing campaign throughout the war.

There are not enough ICU beds — just 148 for a population of more than 3 million in Idlib, half of whom are displaced people. There are only 153 ventilators, according to Save the Children. There is not enough personal protective equipment.

Al-Hiraki told me they have modeled out it and could expect to see a spike in four weeks. The health care system, he said, will collapse in six.

“There really is not the infrastructure to cope with a pandemic in this community,” Barnes said.

The World Health Organization sent coronavirus tests to Idlib in March, and as of June 30, more than 1,600 people had been tested for the virus in northwestern Syria — all negative up to that point, per Save the Children. (The whole of Syria has confirmed more than 458 cases and 22 deaths, according to data from Johns Hopkins University.)

But the health care system still has limited capacity for testing and contact tracing. That does not mean Syrians aren’t trying.

Syria had one of the stronger public health care systems in the region before the war, and that technical knowledge has persisted in the few institutions still operating in Idlib. Sahar Atrache, senior advocate for the Middle East at Refugees International, told me the Idlib directorate still has solid institutions that function and have maintained distance from the extremist groups operating in the area.

They’re coordinating what Atrache called a “combined effort” among the directorate, the World Health Organization and United Nations, and Syrian and international nongovernmental organizations.

And NGOs operating in the country took steps to prepare for Covid-19 as best they could. Barnes said Mercy Corps tried to increase deliveries of hygiene kits, more soap, and more water. Organizations promoted messaging on social distancing, including in camp settings.

But there’s only so far that can go.

“[N]ow that the coronavirus has reached us in Idlib, we are back to quarantining again and trying to find masks and gloves,” Darwish, who lives in Deir Hassan in northern Idlib with his family, told Al Jazeera. “We’re scared it will reach us at the camps. It will be a disaster.”

A United Nations aid route just closed, adding yet another complication

The ability to meet the basic needs of civilians in northwest Syria also just got harder, now that a critical United Nations aid route into Syria has been shut down.

Two UN aid routes from Turkey have delivered critical food and medical aid to northwest Syria for six years: the Bab al-Salam border crossing, which leads to northern Aleppo, and Bab al-Hawa, which goes directly to Idlib. (Part of northern Aleppo is still under opposition control, though Assad has retaken most of the province.)

The mandate was set to expire last Friday, unless the UN Security Council moved to reauthorize it. And some member states, specifically Russia, objected to simply renewing the program. As Assad’s primary backer, Russia wanted to get rid of one of the routes — specifically, the Bab al-Salam route into northern Aleppo.

Russia argued that it violated Syria’s sovereignty and that any aid operations needed to be done in coordination with the Syrian government. As Assad seeks to consolidate control over Syria, these areas are particular sticking points.

“The problem with their argument is the Syrian government is not willing to provide humanitarian assistance to communities who are in opposition-held areas, and those are exactly these areas, it’s northern Aleppo, it’s Idlib,” Jackson said.

Western governments, particularly Belgium and Germany, pushed back, saying the closure could deny more than 1 million people vital aid. Ultimately, the UNSC voted to keep one route — Bab al-Hawa, the one that goes to Idlib — open for 12 months. (Russia, China, and the Dominican Republic ultimately abstained.) The United Nations can no longer deliver aid through the other route, into northern Aleppo.

Representatives from aid groups told me closing off that route will substantially disrupt the ability to deliver aid — with no clear, or rapid, alternative available to make up the difference. Though international NGOs can still use the route, the United Nations cannot — and the UN has been the main logistical channel for getting supplies in, Hardin Lang, vice president for programs and policy at Refugees International, told me.

Jackson from CARE International told me the convoys on the Bab al-Salam route also carried a lot of the medical equipment and PPE brought in to defend against the coronavirus. Those convoys stopped coming in Friday.

And even though the Idlib route remains open for the next 12 months, that crossing was already nearing capacity. “So it’s not simply a matter of, ‘Oh, we’ll just divert those trucks and we’ll get it all out there by a longer route that costs more money,’” Jackson said. “It’s physically not possible to just simply divert the convoys.”

Getting from Idlib to northern Aleppo is challenging. It would involve crossing front-lines, and territories under varying control. Roads and infrastructure are poor, or nonexistent. Plus, it adds hours and hours to any journey. “Capacity, politics, and also just the logistics of access to terrain and who’s controlling it” makes it incredibly difficult to make up the difference, Lang said.

And, of course, this is happening amid a pandemic. Travel restrictions, a global economic crisis, and safety concerns are also complicating the efforts of aid groups on the ground, further restricting their limited ability to scale up.

Idlib — and the rest of Syria — teeters on crisis

Zoom out and the scale of the crisis is even greater. Though the Idlib ceasefire has largely held, it hasn’t entirely eliminated the violence. Other parts of Syria are also seeing renewed conflict, including attacks from ISIS.

The World Food Program estimates that 9.3 million Syrians are now food insecure, a record, and an increase of more than 1 million in just the past six months. Syria’s collapsing economy is making that even worse; the cost of food in Syria has doubled in the past year. New US sanctions, which went live last month, could further damage the economy.

And with the rest of the world consumed by the pandemic, the help that’s needed may be harder to come by. “You have to add to all these challenges — the growing food insecurity, growing poverty, lack of security or social security,” Atrache said.

It is crisis on top of crisis on top of crisis, including the still-unresolved Syrian civil war. “This,” Atrache said, “is the situation inside Idlib.”

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