In March, as the COVID-19 pandemic spread across the globe, the Syrian civil war entered its tenth year. Other humanitarian crises like the one gripping Idlib in northwest Syria moved swiftly off the front page. But that will change when the first cases of COVID-19 are diagnosed in the province. And that is only a matter of time. Idlib, surrounded by virus-struck regions including Turkey, northeast Syria, and Syrian regime-controlled areas, is like a tinderbox waiting for the match. Syrian doctors inside the province and right across the border in Turkey believe the arrival of the virus is imminent. Humanitarian organizations are bracing for the worst.
When the virus hits Idlib, the province will be ill-prepared to cope. Developed economies and advanced healthcare systems are themselves crumbling under the weight of COVID-19. Countries surrounding Syria, including Lebanon, Jordan, and Iraq, have taken drastic measures including lockdowns and curfews to try to contain the virus. But very few of these places face the challenges Idlib does. The province lacks a strong and legitimate authority to impose such measures after years of violence that have decimated its infrastructure.
In addition, a recent Russian-backed Syrian-regime-led military offensive has systematically targeted medical facilities, dealing a heavy blow to Idlib’s healthcare system, killing and injuring thousands, and displacing more than 1 million civilians. Despite a ceasefire on March 5, risks of renewed violence remain high. For many, it is a question of when and not if the truce will collapse. Even with the ceasefire in place, the humanitarian crisis in Idlib remains one of the most acute in the world.
A COVID-19 outbreak will almost certainly exacerbate the province’s underlying problems and worsen an already catastrophic humanitarian situation. There are an estimated 3 million civilians inside the province, and more than half are already displaced from other parts of the country. Throughout the year, they have undergone many hardships. Another blow, in the form of renewed violence or a coronavirus outbreak, would be devastating.
Medical experts and governments across the world have urged their citizens to implement preventive measures for COVID-19. Staying at home, frequent washing of hands, keeping space between individuals, stocking on food, medications, and other essentials, cleaning and disinfecting surfaces, and optimizing medical staff’s use of protective gear are among the many pressing mitigation requirements.1 However, in Idlib, complying with these standards is out of reach for most people.
Between December 2019 and February 2020, a Russian-backed Syrian regime offensive had displaced more than 1 million people in Idlib. This came on top of a previous military campaign which, between February and August 2019, had already forced another 1 million Syrians from their homes. Since 2019, the conflict in Idlib has created the worst displacement crisis of the Syrian war. On average, civilians inside the province have been displaced between five and ten times.2 Towns like Ma’arat al-Nu’man, Saraqeb, and Fakranbul in central Idlib, which were all evacuated during the recent offensive, were already host to hundreds of thousands of internally displaced people (IDPs) who fled southern Idlib in 2019 in the wake of the Syrian regime’s advances.
On February 27, after an Assad regime airstrike that killed at least 34 Turkish soldiers, Turkey launched Operation Spring Shield in Idlib Province. Subsequent clashes between Turkey and the Syrian regime left tens of casualties on both sides. Russia remained initially on the sidelines to avoid a direct confrontation with Turkey, but then intervened as forces backed by Turkey began to seize strategically important population centers deep into the province.
Yet, despite their conflicting interests in Syria, Russia and Turkey appeared keen on preserving their mutual relationship and made efforts to prevent further escalation. On March 5, they announced a new ceasefire, managing “to find common ground on the disputed issues that have arisen, and come to acceptable solutions,” as per the words of Russian President Vladimir Putin. The agreement included the establishment of a security corridor that stretches 6 km (3.7 miles) to the north and 6 km to the south of the Aleppo-Latakia Highway, known as the M4, which is jointly patrolled by Russian and Turkish forces. Although Turkey had demanded that Syrian troops withdraw to the lines agreed upon in 2018 in Sochi, Russia, the March 5 ceasefire indirectly recognized the new lines of control. In these new lines, the territory under the control of opposition groups has shrunk to 3,000 square kilometers, down from 7,000 in April 2019.3
The ceasefire offered a much-needed respite to the civilian population. However, the situation inside the province remains highly volatile. Over the last few years, warring parties reached several ceasefires, but none of them held for very long. The Syrian president has vowed to reclaim the whole of Syria, and his regime is attempting to bring Idlib, the last rebel-controlled area, to heel. For its part, Turkey has been unable or unwilling to curb extremist groups as per previous agreements with Russia, pushing Moscow to support its Syrian ally’s offensives. Thus, the recent deal between Ankara and Moscow hardly guarantees an end to violence. In early April, the Syrian army increased its presence in the southern countryside of the province and has traded attacks with militant groups.
Nonetheless, and despite its many flaws and many breaches from both sides, the ceasefire largely halted the violence and has held for now. The global spread of the coronavirus might be playing a role in maintaining the relative calm in the province as Iran, Turkey, and other warring parties struggle to contain the spread of the virus in their own countries. But Idlib is by no means out of the woods. Thus, the United States and its European partners should spare no diplomatic efforts to convince Ankara and Moscow about the importance of maintaining the ceasefire.
A Protracted Humanitarian Crisis
In Idlib, the new de facto lines of control have boxed nearly 3 million civilians up into a small pocket of the province.4 They now live in an area that, prior to 2011, was home to no more than 500,000 people.5 Overcrowding and limited spaces have pushed families to seek refuge in any place that is available. Schools, mosques, unfinished buildings, garages, and even animal pens and stables have been converted into shelters. Some had nowhere to go but to stay in the open air and under olive trees during the then harsh winter. This has led to several deaths—and in most cases, the victims were children.
At a time when healthcare providers and world leaders call for social distancing, families in Idlib are crammed together in overcrowded and unhealthy conditions. One family often shares housing with two, three, or four other families. “I usually live with my father and mother in a two-bedroom apartment,” one Syrian activist told Refugees International. “Now, my sister and my brother and their families are living with us. We are now 15 people living in a small apartment, sharing one bathroom.”
But it is inside the hundreds of informal camps that the situation is most concerning. These camps now house more than one-third of Idlib’s population. The camps along the border with Turkey are the most overpopulated. The relatively calmer situation along the border has pushed people to amass in the north of the province in search for safety. So far, Russian and Syrian regime forces have largely avoided bombing these camps. Conditions in the camps are almost unlivable. Two or three families are often crammed inside a single tent, making social distancing impossible. “When I recommended to one of my patients to self-isolate,” a doctor in Idlib recounted, “she laughed. I live with 15 other people in one tent, where should I self-isolate?!’ she told me. In Idlib, terms like social distancing, self-quarantine, and self-isolation are a joke.”
For many of the province’s residents, living in a tent has become their new reality. Nearly 10 percent of the 1 million displaced since December 2019 have gone home.6 But most of the displaced cannot return as their villages have been destroyed, retaken by the Assad regime, or are now too dangerously close to the frontlines. While the rest of the world is fighting the coronavirus and enduring the seemingly interminable confinement at home, to displaced people, the idea of being confined in one’s own house seems a luxury. Staying home is a dream for many Syrians. On social media, pictures of Syrian refugees holding signs in front of their tents with such slogans as: “Stay home! I wish I could!” were widely circulated.
Hygiene inside these camps is very poor under normal conditions. However, in the face of the coronavirus pandemic, it takes on a whole new level of concern. Proper hygienic practices are key to preventing the spread of the virus. However, even the simple act of hand washing can be a luxury for many IDPs. Camp residents have limited access to latrines, with dozens of people often sharing the same one. As displacement has put immense strains on water resources, exacerbated by the regime’s targeting of water plants, both potable and running water is scarce. The lack of water has pushed residents to use groundwater wells close to the surface. This, in turn, has led to water-related diseases, the head of Idlib’s Health Directorate, a body of the health ministry affiliated with the opposition-led Syrian interim government, explained to Refugees International. Relief workers say they have conducted sessions to raise hygiene awareness, but without the proper resources, people find these sessions frustrating. “Give me water and soap, and I will wash my hands 100 times a day! A woman in an IDP camp said to me,” an NGO worker told Refugees International. “I didn’t know what to say to her.”
A Decimated Healthcare System
The healthcare system in Idlib is not equipped to deal with a COVID-19 outbreak. Years of Russian-Syrian systematic and relentless bombings targeting health facilities have destroyed the province’s ability to cope with a pandemic. Over the course of this year alone, the fighting has put more than 80 hospitals out of service. Those facilities that continue to function have extremely limited capacity to provide intensive care.7 In some parts of Idlib, the systematic targeting of health facilities has left civilians with no access to healthcare at all.8
In addition, the war in Syria has led to an exodus of physicians across the country. In Idlib, those who stayed are overwhelmed and burned out. There is a lack of doctors, nurses, and specialists, and some of those who remain lack the necessary training. Most facilities inside the province lack the necessary personnel or equipment to treat complicated trauma injuries and some chronic diseases. As a result, patients requiring advanced treatment are sent to Turkey. In the event of a coronavirus outbreak in Idlib, available intensive care units and ventilators will not be sufficient. However, it is unclear if Ankara will allow for COVID-19 patients to seek treatment in Turkey, or if its hospitals might be overwhelmed by the pandemic. In addition, the violence and the systematic targeting of hospitals have put medical staff and patients under great threat. More than 900 medical personnel have been killed in Syria since 2011. These conditions are extremely challenging to say the least. However, they could become catastrophic if coupled with the coronavirus outbreak.
In Idlib, hospitals have fewer than 100 ventilators to treat around 3 million civilians. As of the date of this report, all existing ventilators are currently in use.9 Idlib only received the first testing kits for the coronavirus in late March. Worryingly, the pandemic has led countries not only to close their borders but also to limit medical supply chains. Turkey, for instance, has announced that it will stop exporting locally made face masks as its own medical staff needs them to fight the spread of the virus. However, this rationale is put into question by recent reports that Turkey will reportedly deliver up to 84 tons of Personal Protective Equipment (PPE) to the United Kingdom.
All this is likely to compound the already severe shortage of much-needed PPE for medical staff, relief workers, and the community in Idlib. These shortages will, in turn, put medical staff in Idlib at greater risk. It is vital to prepare it for such an eventuality and for Turkey to ease such restrictions. As for ventilators, it is not clear that Turkey has a sufficient number of ventilators to address the current shortages inside Idlib. However, “if the funding for these ventilators is secured,” explained a Heath Directorate official, “we can import them from China.”
Yet, Idlib medical personnel have demonstrated great ingenuity and resilience. Throughout the years of conflict, doctors, nurses, and other staff have adapted to extremely harsh conditions. Forced to treat serious trauma-related injuries and victims of chemical warfare without resources, the remaining doctors have adopted innovative, makeshift treatment measures to help their patients. Over the course of the war, doctors in Idlib have gained experience in the challenges now being faced by global medical staff dealing with coronavirus. These include treating patients on the floor due to a lack of hospital beds, triaging severe cases, and operating under the threat of contamination when treating patients exposed to chemical weapons. These conditions and the long working hours and exhaustion “are all déjà vu for us,” said one doctor.
The Coronavirus: Adding Insult to Injury
Even before the COVID-19 pandemic, the magnitude of the displacement and destruction left by years of violence made the humanitarian response in Idlib very challenging. The war has destroyed much of the formal economy in the province. Most of the population is destitute, and meeting the most basic needs is a daily struggle. “Many inside the province can’t afford to stay home,” explained a relief worker in Idlib. “People need to work to feed their families, staying home is not an option for them.”
In addition, nine years of war have had a devastating impact on civilians’ health and weakened their immune systems. Exposure to combat, chemical attacks, malnutrition, and grinding poverty have undoubtably resulted in the kind of underlying health conditions that help turn COVID-19 deadly. Environmental conditions have led to a further deterioration in public health. People have been forced to burn plastics, rubber shoes, and other materials into fuel for heating—further contaminating their communities with harmful air pollutants. The rubble and dust caused by the persistent Russian and regime bombing campaigns have contributed to respiratory difficulties.10 “A lot of my patients suffer from respiratory and immune problems caused by the war,” a local doctor told Refugees International. “This makes many prone to greater risks of being affected by the coronavirus.”
In cooperation with the World Health Organization (WHO), the Health Directorate and humanitarian organizations formed a task force to prepare for a coronavirus outbreak. The COVID-19 response includes monitoring various crossing points into Idlib for suspected cases, procuring up to 100 additional ventilators, supporting Idlib’s laboratory’s testing capacity, conducting awareness campaigns, distributing hygiene kits to residents, and establishing three isolation hospitals and 28 community-based isolation centers (CBIC) to receive COVID-19 cases. The funding needed for the response is estimated at $33 million.11
However, donors have been slow to react. So far, no major funds for a COVID-19 response have been secured.12 The United States and European donors should step up their support to help Idlib’s COVID-19 response. Some local groups have stepped in to fill the gaps. They have been conducting awareness campaigns, disinfecting hospitals and public spaces, and supporting hospitals to prepare isolation centers.13 However, this has forced organizations to divert resources from other lifesaving programming, thereby spreading thin the province’s already scarce resources.
Moreover, the pandemic is disrupting humanitarian assistance operations, on which more than two-thirds of Idlib’s population relies. Turkey has closed its borders with Syria, and although humanitarian aid is exempted, the move has slowed the flow of aid. Turkey has also reduced the number of staff allowed to commute between Idlib and Turkey, including doctors.14 This has naturally resulted in the decrease of humanitarian services such as primary healthcare services, schooling, and aid distribution.
More broadly, Idlib lacks a set of institutions capable of exercising legitimate governance. The extremist groups, which control much of the ground, lack either the will or the ability to effectively enforce stay at home policies, social distancing, and other measures designed to slow the spread of the virus. “Nobody is staying home,” explained a cartoonist in Idlib city. “Most are going out, trying to enjoy the absence of airstrikes from the sky. We live in constant fear, and now that there is a ceasefire, people want to have a normal life despite the coronavirus,” she said. Another activist went even further: “We’ve seen it all, chemical attacks, phosphorus, bunker busters, cluster bombs, barrel bombs, and we stood in the face of them. Do you think a virus is going to scare us?” he told Refugees International. Communicating the risks of COVID-19 to Idlib’s population, especially in IDP camps, in a manner that results in behavior change will be challenging for aid workers, to say the least.
Conclusion and Recommendations
Idlib’s civilian population and the relief groups that support them face two daunting challenges: the collapse of the ceasefire and the outbreak of COVID-19. Each one on its own carries potentially catastrophic consequences. If the Syrian regime offensive resumes in earnest, the fate of more than 700,000 people now living Idlib city will be in the immediate balance. While aid agencies must plan for the collapse of the ceasefire, they must also move quickly to prepare a highly vulnerable population for the inevitable arrival of COVID-19. To do so, they will need a full court diplomatic press from capitals to shore up the ceasefire – despite its flaws – for as long as possible. If the truce holds, it will give donors, humanitarians, and Idlib’s traumatized communities some hope staving off the worst of the pandemic.
- The United States and the European Union (EU) should provide diplomatic support for the Turkish-Russian ceasefire. They should use all available diplomatic resources and channels to communicate to Moscow and Ankara the importance of maintaining the truce.
- The United States and European donors should prioritize the funding of the shelter sector to help alleviate overcrowding in Idlib province. Local organizations should use this funding to prepare additional camps to ease the overcrowding in existing IDP camps and reception centers.
- The United States and European donors should step up their funding to the healthcare system inside Idlib province. They should provide the $33 million required to help the WHO, international NGOs, local organizations, and medical facilities increase their preparedness for a coronavirus outbreak and procure the necessary supplies and equipment.
While awaiting funding for the COVID-19 response to be secured, local groups should dedicate some existing resources to deliver essential goods including food, soap and clean water, and sanitizers to IDP camps. They should also redouble their efforts to sensitize residents about the importance of preventive measures against the coronavirus.
- Turkey should ease restrictions on the procurement of PPE destined for Idlib.
- In the event of a coronavirus outbreak in Idlib, countries with a sufficient stock of ventilators, such as China, should facilitate the procurement of ventilators for use inside Idlib.
 Centers for Disease Control and Prevention (CDC), “Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission,” March 12, 2020.
 Phone interview with a UN official based in Turkey, February 15, 2020.
 In September 2017 when a de-escalation agreement has prevented large military operations in the area, armed grouped controlled more than 9,000 square kilometers.
 The United Nations Office for the Coordination of Humanitarian Affairs (OCHA), now estimates that nearly 2.6 million live in opposition-controlled areas as 400,000 residents fled to Turkish controlled territory in northern Aleppo. However, residents and humanitarian groups assure that numbers are much higher. Interviews with relief workers, activists and a local monitoring group representatives inside Idlib and in Turkey, February-March 2020.
 Interviews with relief workers and a local monitoring group representatives inside Idlib and in Turkey, February-March 2020.
 Response Coordination Group, “Returnees update,” April 8, 2020.
 Phone interviews with medical staff in Idlib, March-April 2020. https://www.msf.org/covid-19-complicates-catastrophic-situation-northwest-syria
 Interview with the Head of Idlib’ Health Directorate, Turkey, February 25, 2020.
 Phone interview with a Health Directorate official, April 21, 2020.
 Phone interviews with doctors and residents in Idlib, February-April 2020.
 Phone interview with a Health Directorate official, April 21, 2020.
 Phone interview with a representative of the Syrian NGO Forum, April 16, 2020.
 Phone interviews with representatives of NGOs and doctors, March-April 2020.
 Phone interview with the coordinator of a medical organization in Idlib, April 5, 2020.