key: cord-0781253-22iripr9
authors: Abbara, Aula; Rayes, Diana; Fahham, Ola; Alhiraki, Omar Alrashid; Khalil, Munzer; Alomar, Abdulrahman; Tarakji, Ahmad
title: Coronavirus 2019 and health systems affected by protracted conflict: the case of Syria
date: 2020-05-08
journal: International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases
DOI: 10.1016/j.ijid.2020.05.003
sha: f21dc2f5bb84cda75094ac8b174576154af39350
doc_id: 781253
cord_uid: 22iripr9

Abstract Introduction Two thirds of countries globally are unprepared to respond to a health emergency as per the International Health Regulations (2005) with conflict-affected countries like Syria particularly vulnerable. Political influences on outbreak preparedness, response and reporting may also adversely affect control of SARS-CoV-2 in Syria. Syria reported its first case on 22 March 2020 however concerns were raised that this was delayed and that underreporting continues. Main Syria's conflict has displaced more than half its pre-war population leaving 6.7 million people internally displaced; consequent overcrowding with insufficient water, sanitation and healthcare (including laboratory capacity) could lead to conditions which are ideal for spread of SARS-CoV-2 in Syria. Political changes have led to the formation of at least three health systems within Syria's borders, each with their own governance, capacity and planning. This fragmentation with little interaction between them could lead to poor resource allocation and adversely affect control. As such, COVID-19 could overwhelm the health systems (particularly intensive care capacity) leading to high deaths across the population, particularly for the most vulnerable such as detainees. Conclusions Locally implementable interventions which rapidly build WASH and health system capacity are required across Syria to ensure early detection and management of COVID-19 cases.

In the Middle East and North Africa region, political instability, a lack of transparency and 62 fragmentation along political divisions may affected preparedness. Syria, a country which has now 63 entered the tenth year of a conflict which has displaced more than half of its population (6.7 million 64 internally and 5.5 million as refugees) is particularly vulnerable with a fragmented and increasingly 65 politically influenced health system. 2 This is alongside concern that the presence of high numbers of 66 COVID-19 cases in neighbouring countries, particularly Iran and Turkey, could have introduced cases 67 before Syria declared the closure of its borders on 23 March 2020 3 as even after the formal border 68 closures, some movement continued across less formal borders. Turkey is home to around 3.6 million 69 Syrian refugees and is also in the top ten countries with the highest number of COVID-19 cases with 70 120,204 confirmed cases (as of 28 April 2020.) 4 71 72

In this commentary, we address issues relating to COVID-19 in Syria including political influences on 73 public health and what measures are being taken to mitigate potential consequences of COVID-19 74 spread in a country whose health system has been decimated by years of conflict.

More than half a million civilians have been killed directly by the conflict. 5,6 This conflict has 82 rendered less than 50% of health facilities functional and led to the exodus of nearly 70% of the 83 qualified healthcare workforce with limited opportunities to train new healthcare workers 84 sufficiently. 7,8 In Syria, even before the onset of conflict, the health system lacked sufficient public 85 health infrastructure with inadequate surveillance or strategic preparedness. 7 Both before and since the 86 onset of conflict, politics has influenced the response to communicable diseases outbreaks, something 

Syrian people to suffer again amid regime's virus 256 denial

War-torn Syria braces for lockdown after first virus case

Mazen Kewara AT. Humanitarian 263 catastrophe for civilians in northwest Syria

Gharibah, Mazen; Mehchy Z. COVID-19 Pandemic: Syria's Response and Healthcare 276 Capacity

Syrian Arab Republic: COVID-19 Update No. 03 -25

Wash Our Hands? Some People Can't Wash Their Kids for a Week

Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2. Emerg Infect Dis

Fears over hidden Covid-19 outbreak in Lebanon, Iraq and Syria. The Guardian

WHO Gaziantep Field Presence, Turkey (Medical Portable Ventilator Machine)-291 Availability of Health Equipment Monitored through HeRAMS Tool

Communicable disease surveillance and control in the 295 context of conflict and mass displacement in Syria