On 10 September 2020 Dr Adnan Al-Jasem became the first doctor in northern Syria to die from coronavirus.
Al-Jasem had fled the bombings in Deir Ezzor in the east of the country and tended to the wounded throughout Syria's nine-year long war. Yet it was the virus he died of whilst working as an anesthetist-resusicitator at the Al-Farbi Hospital in Al-Bab, Aleppo region.
In northwest Syria there are only 600 doctors for the 4 million inhabitants who live there – that's 1.4 doctors per 10,000 people. "They operate 500,000 free medical acts per month," explains Maroussia Simonin, a communications officer at the UOSSM, a coalition of NGOs providing medical care in Syria. "Their health and well-being are essential and vital in order to continue to help and serve the Syrians."
The 9,000 square kilometres that make up northwest Syria include parts of Idlib, western Aleppo, north Hama and eastern Latakia. As bombardments have hit other parts of the country, the population has swelled in the region that runs along the Turkish border. Some 65 per cent are there after being forced from their homes.
In 2019, the Syrian regime and its allies intensified attacks here, including on health care facilities, a familiar strategy undertaken across the country since the start of the war which has left hospitals unable to cope with covid.
"Nine years of conflict has left Syria's healthcare system at the brink of collapse," says Munther Bulad, UOSSM programme manager for northwest Syria. "Between the start of the conflict and February 2020, 595 attacks were conducted on at least 350 separate health facilities, and 923 medical personnel were killed. 536 of these 595 attacks were conducted by the Government of Syria and its allies."
Since the start of the conflict, out of the 111 public hospitals in Syria, roughly one quarter have been fully destroyed. "On March 6, 2020, a UN report stated that up to 70 per cent of the health workers had left the country as migrants or refugees," he adds.
Across the world, whilst countries assess whether or not they are entering their second wave of COVID-19, northwest Syria is still at the beginning of its first. The virus did not actually hit the region until August this year, some eight months after other countries began to grapple with their first cases.
As of 24 September, there were 760 confirmed cases in northwest Syria – all analysed at the only medical laboratory in NW Syria – some 35 per cent of which were health care workers. This is compared to the 3,765 confirmed cases in regime-held territory, recorded up to 19 September.
Ahmed Idrees, who works for the Takaful Al-Sham charity and is based in Aleppo Province, told me that beyond the camps the death and infection rate from coronavirus in opposition-controlled areas is still very low.
"The liberated areas are closed and isolated from the surrounding areas," he explains, "which reduces the severity of the entry and spread of the virus."
"The region here is isolated from the outside world. There is an absence of airports, trains and crossings with other countries which helped delay the arrival of the virus to the region."
However, he is afraid for what is to come: "The population density, congestion in the camps and the absence of international organisations concerned with fighting the virus make us anxious about its spread."
As winter approaches in one of the top, most at risk parts of the world, cases are going up.
Chamsy Sarkis, who recently conducted a study into coronavirus in northwest Syria, told Bawaba in August: "If there was a virus outbreak in 10 to 20 of the camps out of 1,000 that are spread across Idlib alone, the health care system would collapse in weeks."
"Each camp hosts an average of 1,000 IDPs and in less than two months each camp will have about 100 severe or critical cases in need of a ventilator and an intensive care bed. For 10 camps only we predict the need for 1,000 places in ICUs, which is already beyond the healthcare capacity of northwestern Syria."
In March 2020 there were 201 intensive care beds and 95 ventilators across northwest Syria, Simion tells me, and just one hospital bed per 1,363 people.
Whilst the central message throughout the global pandemic has been social distancing and frequent handwashing, tents for internally displaced people are occupied by several different families who share toilets and their water supply. There is no sewage system.
"All the basic elements to prevent an epidemic are clearly lacking in Idlib Province," says Simion.
Added to this, many of the IDPs already suffer severe respiratory problems, such as tuberculosis. "Chronic illnesses are devastating in refugee camps, where it is an obstacle course to get the right treatment," says Dr Ahmad Al-Hassan, a pulmonologist at UOSSM's Qooreena Centre in Idlib Province. "We are alarmed by the drug shortages we face. Add to that a possible COVID-19 pandemic, and we'd be totally overwhelmed by the situation … We can't even afford to change masks between two patients."
One Syrian I spoke to said he had read little in the media about covid in Syria but noticed with alarm how many people were posting tributes on Facebook for friends and loved ones taken by the virus. A recent report carried out by researchers at Imperial College London showed that only 1.25 per cent of deaths from coronavirus are being reported in Damascus.
"Civilians in areas under the Syrian regime control are already suffering from a decade of conflict and economic crisis, add to that the corruption and mismanagement of the regime to protect civilians from a global pandemic," Ranim Badenjki, communications officer at the Syria Campaign told me.
Also of concern, says Badenjki, is the thousands of political prisoners being detained in poor, unhygienic conditions among whom an outbreak would spread rapidly.
"The number of cases and deaths of COVID-19 has drastically increased in the past weeks and it is being underreported by the authorities and WHO in Syria. Doctors and medical workers are left alone to deal with this crisis, they're being intimidated by security not to speak up about the deteriorating health situation."
Yet when they can, they do. An anonymous Syrian doctor told the Guardian in August that one hospital in Aleppo is running out of body bags and that patients are treated in dirty, overcrowded rooms with limited medication and instruments. There is a lack of PPE and testing, whilst some people are even trying to buy their own oxygen and ventilators.
Gasia Ohanes, a Lebanon-based journalist covering the covid outbreak in Syria, told me that in Aleppo hospitals are running out of medicine and are treating patients amid severe electricity and water cuts.
"People in Aleppo have to bribe hospital staff to get a bed and are told to secure their own medicine," she told me. "One person told me she went to 11 pharmacies in Aleppo before she could find vitamin c tablets."
In Latakia, also a regime held city, there is a shortage of medicine, she adds.
Sami, a pharmacist living in the capital, told the Syria Campaign that testing in Damascus is considered a privilege and the only place it now takes place is Al-Jalaa Centre after other sites were shut down. It takes around one week or 10 days to get an appointment, he said.
Whilst one of the problems is limited testing within Syria, The Ministry of Health has imposed a mandatory PCR test for anyone wishing to travel from Syria, overland through Beirut Airport. The test, which costs $100, must be carried out in approved centres based in Damascus.
Activists online have mocked the measure, accusing the regime of using them to accumulate hard cash, since a test at Beirut Airport is a quarter of the price. The measure was introduced just weeks after the government made it a requirement that $100 must be converted to Syrian currency for people to enter Syria.
It has had tragic consequences. At the beginning of September, 17-year-old Zainab Al-Ibrahim died at the border after not being allowed into the country because she didn't have the entry fee.
Back in northwest Syria, the embargo and restrictions imposed on the checkpoints by the Syrian regime's security services means that IDPs are finding it difficult to secure protective equipment, explains Bulad: "Pharmacies sell masks and gloves at high prices, with each mask costing 500-1,000 SYP ($0.25-$0.50.)"
War, inflation, a searing economic crisis and US sanctions means the average Syrian lives on just $4 a day. With the rise in price of medicine, vitamins, and sanitiser, many must choose between eating and fending off coronavirus.
The views expressed in this article belong to the author and do not necessarily reflect the editorial policy of Middle East Monitor.