The health system is not only decimated, however, it is also fractured into four separate and increasingly disconnected health systems which function within Syria’s national borders. Political divisions have led to the fragmentation of the country into different zones of control: northeast Syria is under de facto Kurdish control; the northwest, led by the Syrian National Coalition, is under opposition control; other areas in the north are controlled by Turkey and the remaining two-thirds of the country is ruled by President Bashar al-Asad’s government. Each of these zones has seen the evolution of a regional health system through which health care is delivered to the increasingly vulnerable populations under their control. The COVID-19 pandemic has exacerbated and highlighted differences between the subnational health systems and exposed their internal weaknesses.
Each subnational health system evolved, after the onset of conflict, with its own structures, leadership, governance and funding streams. In areas outside of government control, various groups emerged to fill the void left by the withdrawal of the Ministry of Health and related providers, leading to increased fragmentation and politicization of their health systems.
A particular challenge facing the provision of health care in Syria is that there is increasingly little communication or collaboration among these subnational health systems, which has contributed to disjointed and inadequate responses to the spread of COVID-19 and unsustainable pressures on health care workers.
Disparate Responses to COVID-19 Within Syria
The response in Syria to the coronavirus pandemic has been significantly affected by the failure of the United Nations Security Council to renew the cross-border resolutions, which had previously allowed aid from neighboring countries to enter areas outside of government control. The first resolution (number 2165) was passed unanimously in 2014 and allowed four border crossings to open. It was, however, subject to annual renewal. In January 2020, the failure of a full renewal led to the closure of Yaroubieh border crossing on Syria’s border with Iraq, affecting aid to millions in northeast Syria who are now forced to rely on aid through Damascus. Unfortunately, this has led to interruptions in the flow of aid due to bureaucracy and perceived interference with aid, resulting in adverse effects on local COVID-19 responses. For example, although the World Health Organization (WHO) has provided training, equipment (including PCR testing machines) and personal protective equipment (PPE) to Damascus, little of this has reached northeast Syria with perceived prioritization to areas directly under government control.
Even in government-controlled areas, however, the health system is degraded and unable to meet the needs of the population. Poverty affects 80 percent of the population, unemployment rates are high and inflation is increasing rapidly. Bread queues are seen more often. This economic collapse, which comes on the back of protracted conflict and the effects of the COVID-19 pandemic, has had a direct effect on the ability of increasingly desperate civilians to access a health care system that is heavily privatized and reliant on high out of pocket expenditures. There is also a continued, heavy emphasis on specialist, hospital-based care with an under-developed primary health care system, increasing the cost burden on service users who prefer to access private care if they are able to, even if this pushes them into debt. The quality of services is poor, particularly of public health facilities, making patients even more reluctant to access them.
In opposition-controlled northwest Syria, the need to fill the role of the Ministry of Health has resulted in the presence of multiple organizations that stepped in to provide oversight and planning and to support the health and humanitarian response. The presence of these sometimes competing bodies (including international organizations as well as local and expatriate humanitarian groups) has led to a disconnected, underfunded and poorly coordinated humanitarian system that is not adequately responsive to the COVID-19 outbreak in the area. In March 2020, the WHO-led health cluster in Gaziantep, Turkey established the COVID-19 Task Force which consists of local and international humanitarian organizations in northwest Syria. Their role is to provide technical support to health care providers in this area, for example, they have supported the establishment of COVID-19 isolation units and hospitals. The response, however, has been delayed, underfunded and inadequate to meet the needs of rapidly rising cases.
The health and humanitarian response to northwest Syria, including for COVID-19, has been adversely affected by the closure in July 2020 of Bab al-Salam border crossing between Turkey and Syria. The Bab al-Hawa crossing is now the only lifeline for around 3–4 million civilians who rely on it for essential health and humanitarian aid as well as COVID-19 related supplies. At least half of the civilians in this area (2.5 million) are internally displaced people who fled bombardment in other parts of the country, which have now been retaken by the government, such as Aleppo, the Damascus suburbs and Homs. Around 1.5 million still reside in camps. Attacks on this area including on health facilities continue causing further detriment to the local health system and its ability to respond to the health needs of the population.
The smaller geographical areas that have been under Turkish control since 2016 have been incorporated into the Turkish health system. The managers of health facilities are Turkish, but most of the health care workers are Syrian, which at least minimizes discrepancies in care and language barriers between the northern zones that are outside Syrian government control. Nevertheless, a lack of communication between the Turkish areas and the adjacent zone under Syrian opposition control persists with particular concerns for the spread of COVID-19 as communications about outbreaks and contact tracing are not freely shared.
The Plight of Health Care Workers
The COVID-19 pandemic has strained all parts of the health system in Syria, but the most significant burdens have been on health care workers at the frontlines of the response. Across all geographic areas of Syria, there is insufficient PPE and testing capacity, including for staff, and poor infection control practices leading to increased risks. Ola Fahham, a physician working in northwest Syria, explained via telephone in September 2020 that “the lack of PPE forces health care workers either to reuse their N95 masks multiple times or rely on inadequate home-made masks and face shields, which put them at risk.” She also reports that the shortage of health care workers means that doctors are forced to work in more than one health facility, potentially contributing to the spread of the infection.
According to Human Rights Watch, dozens of doctors in Syria have reportedly died of COVID-19 since the start of the pandemic. Syrian doctor and public health expert Fouad M. Fouad emphasizes that the effect of “the number of doctors who are dying is difficult to comprehend in a health system which is already short of doctors. In one day, four doctors, each with at least 25 years of experience, died from COVID-19.” The loss of these experienced doctors compounds the stresses on a health care system already severely undermined by the decimation of war and the exodus of thousands of its expert health professionals.
In opposition-controlled northwest Syria, the Early Warning and Response Network (EWARN) surveillance system showed early estimates of at least one quarter of the total number of COVID-19 cases occurring among health care workers after the first case was described in the area on July 9, 2020. Health care workers not only fear contracting COVID-19 but also risk reprisals from the public as local media reports often hold them responsible for the transmission of infection, further contributing to misinformation and mistrust. Omar al-Hiraki, a physician working in northwest Syria, explained the double burden of the pandemic’s impact: “the COVID-19 pandemic has exhausted health systems in Europe and the United States, which are unaffected by conflict, but in Syria the health system has already been destroyed even before the COVID-19 pandemic. This means we don’t have enough tests and we rely on insensitive questionnaires and clinical examination to support diagnosis.” In addition, he points out that threats and assaults on health care workers could increase if the system becomes so overwhelmed that hospitals cannot admit all those that need care. These serious concerns are a heavy psychological burden on health care workers who also worry about conflict flaring up, further military attacks and targeting of health facilities.
Political Pressures Take a Toll
Especially in areas under the control of the Syrian government, a politicized response to the pandemic has led to accusations that health care workers are being silenced and threatened. In September 2020, for example, the Syrian Observer online news service reported that Nabough al-Awa, the dean of the Faculty of Medicine at Damascus University, was removed from his position after he criticized the government’s response, particularly with regard to the re-opening of schools.
The government’s attempts to censor the flow of information has further increased mistrust in the government, with many people also questioning the low official COVID-19 figures. Official estimates declare less than 10,000 cases in areas under government control whereas neighboring countries such as Lebanon, Jordan and Iraq report 145,000, 150,000 and 573,000 cases respectively. In northwest Syria, 18,000 cases have been reported through EWARN (and not counted in the official figures). Anecdotal evidence from local doctors indicate that there has been a significant increase in the number of cases in areas under government control, along with insufficient means to test, isolate and contact trace or provide adequate management. Patients are afraid to go to already overwhelmed hospitals because they are wary of the deteriorating quality of care and the increasing risk of contracting the virus at the hospital. The government has instructed doctors not to declare COVID-19 cases or report real death numbers, enforcing the orders with threats of reprisals.
According to Hamza al-Kataeb, a Syrian physician now based in London who worked in eastern Aleppo during the siege of 2012–2016 and is in contact with colleagues in Syria: “corruption is widespread in areas under government control. Through bribes and connections, especially to officials in the military, individuals can be exempt from self-isolation or quarantine even if they have been a contact of a known positive case.” For some people, the fear of being asked to quarantine, often away from their families, is enough to deter them from declaring symptoms or reporting that they have been in contact with someone who tested positive.
The moral injury of attempting to provide care in a degraded health care system where preventable deaths continue will have lasting impacts on the country’s health care workforce. As Ola Fahham explains, “Health care workers have already burned out over the past nine years of war in northwest Syria, and now the COVID-19 pandemic has emerged to put them under further massive pressures both physically and psychologically.”
The incredible challenges of post-conflict rebuilding cannot be met without a functioning national health infrastructure. Fouad M. Fouad notes that, “investing in and protecting the health care workforce in Syria is essential to supporting the current COVID-19 response, but also to ensuring the presence of a trained and resilient workforce to rebuild the health system in the post-conflict phase.” A necessary and increasingly important part of supporting health care workers and their patients is to increase collaboration and communication among the different subnational health systems to mitigate the dire effects of a politically and geographically fragmented health infrastructure.
Author’s Note: I would like to thank Omar Dewachi and Diana Rayes for their comments and suggestions as well as the doctors who provided quotes and up to date information.
[Aula Abbara is a consultant in infectious diseases and an honorary senior clinical lecturer at Imperial College, London. She co-chairs the Syria Public Health Network, a policy and advocacy group.]
 Abbara, A. et al. “Coronavirus 2019 and Health Systems Affected by Protracted Conflict: The Case of Syria,” International Journal of Infectious Disease 96 (July 2020).
 Interview with author by email, September 2020.
 Interview with author by telephone, September 2020.
 Interview with author by telephone.