What has been the pandemic’s reach in Syria, in both regime and opposition-held areas? 

The number of cases under Syrian regime control is around 19 cases. But those are the confirmed cases. We don't know how many asymptomatic individuals are carrying the virus, or even spreading the virus. I hope that regime areas are meeting the WHO recommendations. I don't know the status of the surveillance system there, but we do know they were hiding the cases. There are labs in Aleppo that were asked by intelligence forces to misdiagnose cases that looked like COVID-19.  Physicians were forced to reject any COVID-19 diagnosis even when they knew it was this virus, when they could tell it was a new disease they haven’t seen before. Whatever they are asked to diagnose by the regime, they diagnose. Only that. In these areas, COVID-19 tests are completely controlled by the administering institutions under regime control. And those people report whatever they are asked to report. So we don't know the impact now of COVID-19. 

In the opposition areas, people are eager to show reality. And sometimes, unfortunately, they exaggerate. But, in many ways, that’s good for the task force. At the very least, we receive tips that push the response team to go and check for any triggers. Even with these tips, we have yet to confirm any cases of COVID-19 in northwest Syria. The task force does not know if this is because we couldn't identify patient cases, or because actually there are no cases. A good surveillance system will absolutely identify cases at early stages, but the current reporting of COVID-19 to our surveillance network is not efficient because of the weak capacity of healthcare facilities to handle suspected cases from the time of patient admission to their testing.

What measures are being taken by the COVID-19 task force?

We, members of the WHO Task Force, asked Syrians in the northwest to stay home or provide help to those who cannot leave their homes. Our goal is to protect the most vulnerable groups. Recently, our current surveillance system in northwest Syria received test kits from the WHO. This system, the Early Warning Alert and Response Network (EWARN), is the sole field organization receiving test kits, equipment, and training for all health facilities to identify cases that meet the criteria for COVID-19.  I was one of the main co-founders of this system in 2013, which helped us in our response to the polio outbreak in October of the same year. EWARN works to monitor communicable diseases, enhance the health facilities’ reporting mechanisms, manage sampling and testing logistics, and generate regular reports to describe the epidemiological situation in the region. EWARN also spreads awareness and participates in response activities. During the polio outbreak, a team of Syrian physicians and health volunteers, including myself, launched a core coordination effort with UN agencies, the WHO, and international and local NGOs to create the Polio Control Task Force that led the response against the outbreak in coordinate with different donors.

We did the same to launch the COVID-19 task force, which is now operating from Turkey. It's efficient because there's only one body that's coordinating this, so donors can all go to one party.  We use the EWARN’s system of CDC-trained field officers, doctors, and pharmacists who collect information from all the field health facilities. These health workers report to the EWARN system on a daily and weekly basis from almost 550 small, medium, and high-level health facilities from the entire northwest region. But the facilities are poorly-equipped with a very basic hygiene environment. They are barely managing the cases for the chronic diseases or surgeries they are already handling. So any added challenge will completely collapse it. No other support was sent from Turkey or from the task force for COVID-19. It's only those kits and some technical guidance. Otherwise, everybody now in the field is managed by the locals and the public. That's it. There are some donations from here and there but only for minimum capacity.

Preparedness looks like having enough hospitals, enough beds, and capturing the exact number of confirmed cases. These targets are essential, but at the same time, it's awareness campaigns and social mobilization efforts that will really address the virus. This virus can spread to levels that no single healthcare system in the world now can handle. As public health experts in the community are saying, we need more social mobilization and more awareness campaigns. So that's my responsibility. Engaging the public to understand the seriousness of this issue, to actually be part of the designing of the interventions and to provide feedback in the very early stages. This is why the task force is creating public-driven and public-designed interfaces for the public to follow. We have to include different communities, different backgrounds, different ethnicities, and different religions. All of these groups must be a part of the designing of the intervention, the designing of the response itself. Leadership is very important here. People have to help each other to stay at home because—we cannot ask people just stay at home in Syria. Many are internally displaced persons (IDPs), elderly, or impoverished, and have nowhere to go. The IDPs in northwestern camps are in the most dangerous situation due to COVID-19. They live in small tents where they can only walk or move when they go out of the tent. As such, the whole camp is exposed to one another on a daily basis. The spread of COVID-19 will be especially catastrophic in these camps since they already have poor hygiene conditions and a lack of advanced health care services. We may share the benefit of people staying at home, or in their tents, but we have to share also the cost of asking vulnerable populations to stay inside, we have to share the responsibility to help them.

How will a viral outbreak alter the relationship between civilians and their leaders, in both regime and opposition-held areas?

In 2013-2014, the polio crisis strengthened civilians’ relationship with their leaders in the entire northern opposition areas, from Latakia to Hasakah and Deir ez-Zor. You cannot imagine how it strengthened the civilian administration in this region versus the military one. The public deeply trusted their leadership in this area. This is because those in charge took the right decisions, they showed responsibility, and they worked tirelessly. The public quickly came around to this leadership and adopted the interventions and campaigns of civilian-led institutions in northern Syria. Yet, the crisis can be politicized. When the UN doesn't provide efficient support to this region, similar to the support they are providing to Damascus, we all, as parties responding to the crisis, will lose the civilians' trust that has been built in the last couple of years in the local healthcare leadership in this region. We risk this happening at a very sensitive time when we all need to utilize this trust and relationship to convince the public to follow the WHO recommendations.

This is not so much the case in regime areas, there is a different relationship there. Whatever the regime decides that people should do, they will order people to do, and with no trust at all; we don't expect real commitment from the public. In the opposition areas, people still care about this relationship. Yes, the situation is catastrophic in this region, but civilians still have a margin of freedom of speech and rights in general.

What sort of long-term impact do you foresee for northwest Syria?

The regional strategy in northwest Syria should be focused on the early stages of the response: awareness, stopping the circulation of the virus, and helping the most vulnerable groups, like the elderly, the impoverished, and the displaced in camps along the Turkish border. We don't want to reach the level of, “Oh, let me see the capacity we have left in our hospitals.” That stage is dangerous. It is when we will lose the battle. We just don't have the capacity in the already exhausted, very poorly-equipped healthcare system. We cannot risk overwhelming the very few remaining healthcare forces.

Overall, Syria is already isolated. The area itself of northwestern Syria is also isolated. Nobody will go there for tourism. There is no official way to go back and forth but for humanitarian workers. Just very specific lists of people can go back and forth, and it's already controlled by Turkey. The Turkish Government can monitor and control those frequently moving back and forth, but at the same time, we need to make sure COVID-19 does not get in there. Once it’s in there [northwestern Syria], it's going to be really, really bad. 

Dr. Khaled Almilaji is a Toronto-based Syrian physician and a senior consultant for Sustainable International Medical Relief Organization (SIMRO), an NGO-member of the World Health Organization task force currently addressing the spread of COVID-19 in northwest Syria. He is best known for his leading efforts in inoculating 1.4 million Syrian children during the 2013-2014 polio outbreak.

Sandy Alkoutami is a Junior Fellow with Carnegie’s Middle East Program. She conducted this interview for Sada.