key: cord-0819818-4bhrf2zx
authors: Daw, M. A.
title: The impact of armed conflict on the epidemiological situation of Coronavirus disease (COVID-19) in Libya, Syria, and Yemen.
date: 2021-02-16
journal: nan
DOI: 10.1101/2021.02.12.21251654
sha: 7499c95712be9ec1b5b743371d55543fe0e95799
doc_id: 819818
cord_uid: 4bhrf2zx

Background: Since the Arab uprising 2011, Libya, Syria, and Yemen have gone through a major armed conflict. This resulted in a high rate of mortality, injury, and population displacement with a collapse of the health care system. Furthermore, it was complicated by the emergence of, COVID-19 as a global pandemic which made the population of these countries strive under unusual conditions to tackle both the pandemic and the ongoing wars. The objectives of this study were to determine the impacts and influence of armed conflicts on the epidemiology of Novel Coronavirus (SARS-CoV-2) within these war-torn countries and outline the needed strategies to combat the spread of the pandemic and its upcoming consequences. Methods: The official and public data regarding the dynamics of armed conflict and the spread, of SARS-COV-19 in Libya, Syria, and Yemen were collected from all available sources. Starting from the early emergence of the COVID-19 in each country until the end of December 2020. Datasets were analyzed through a set of statistical techniques and the weekly resolved data were used to probe the link between the intensity levels of the armed conflict and the spread of the pandemic. Results; Data indicated that there is an increase in the intensity of violence levels at an early stage from March to August reached up to two folds in the three countries particularly in Libya. In this violent period, few cases of COVID-19 were reported ranging from 5-53 cases/day. From September to December, a significant decline in the level of the armed conflict was accompanied by steep upsurges in the number of reported COVID-19 cases reached up to 500 cases/day. The highest accumulative cases of COVID-19 were reported in Libya, Syria, and Yemen respectively. Conclusions: Our analysis demonstrates that the armed conflict has provided an opportunity for SARS-COV-19 to spread. At the early weeks of the pandemic that coincided with high levels of the armed conflict few cases were officially reported indicating a vast undercount, which may suggest a hidden mitigating spread at an early stage. Then the pandemic increased immensely as the armed conflict decline to reach the highest by December. A full-blown transmission of the COVID-19 pandemic in these countries is expected. Therefore, urgent national and international strategies should be implemented to combat the pandemic and its upcoming consequences.

Armed conflicts have major impacts and immense consequences that are difficult to deal with. Historically, one of the most devastating environmental consequences of war is the disruption of peacetime human-microbe relationships, leading to outbreaks of infectious diseases. War produces a multitude of opportunities for pathogenic microbes and constitutes an extremely effective way to promote microbial traffic and increase human morbidity and mortality (1) . In the Early Modern Age, when persistent conflicts marred the European continent, the spread of plague (caused by Yersinia pestis) was probably aggravated and enhanced through populations fleeing war zones, increasing the geographical range of epidemics (2) . During the global pandemic spread of COVID-19, the technically advanced countries focusing on the domestic impact of COVID-19 just as the disease is likely to spread to poor and war-affected countries. Which has the potential to wreak havoc in these fragile states. This is evident in Libya, Syria, and Yemen who have been locked into incredibly destructive armed conflicts for almost a decade now (3) . The conflict has resulted in a high rate of mortality, remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint injury, and population displacement. Further to severe destruction of health care system which makes it profoundly ill-prepared for COVID-19 (4).

The oil-rich country of Libya was plunged into chaos after a 2011 NATObacked uprising toppled and killed the long-standing socialist leader Mummer Gaddafi and split the country into two riving governments (5) . In Syria States & Iran (6) .

In Yemen, after the 2011 uprising broke out, the country went through a series of political upheavals and cycles of violence that tore the country apart.

Including the start of a full-scale civil war in 2014 and the Saudi-and UAE-led intervention in 2015. This resulted in nearly 100,000 people have died 250,000 displaced and 80% of the population need assistance and protection. Which added further complexity to the COVID-19 pandemic and control measures in such conflict zone (7) . remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

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The healthcare system of these three countries at the brink of collapse that alleviates the spread of epidemics. They were the last countries that reported COVID-19 cases in the MENA region. In Syria, the country's first confirmed case of COVID-19 was reported on March 22, Followed by Libya on March 24, and lately in Yemen on April 10 th , 2020 (8). These countries are in an extraordinarily poor position to confront the COVID-19 pandemic. Instead of the pandemic leading towards the uniting of local, regional, and international actors involved in these countries around a common purpose, conflict dynamics have hampered an effective response to COVID-19 (9) . Furthermore, continued armed conflict would hinder efforts to fight coronavirus and thus act as a catalyzer, and trajectory consequences are expected. However, the influence of armed conflicts on the dynamics of COVID-19 is multifaceted. In this study, we aimed to analyze the impacts and repercussions of the armed conflict on the epidemiological situation of COVID-19 in Libya, Syria, and Yemen and outline the needed strategies to combat COVID-19 and related consequences in these violent regions.

remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, 

All official and public data regarding the dynamics of armed conflict and the emergence, of SARS-CoV-2 covering the three war-torn countries ( Libya, Syria, and Yemen) were collected from the onset of the COVID-19 pandemic till the end of December 2020.

The data for the COVID-19 pandemic were collected from the three countries included in the study. During the period starting from March 2020 till December 2020. This includes the number of total confirmed cases, deaths, and the overall recovered persons from COVID-19. Such data were collected from the official data of the Libyan Ministry of health ( (https://ncdc.org.ly/Ar/) and daily reports on its Facebook page about PCR-confirmed infections, deaths, recoveries, and other remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, Libya, and Yemen (11) .

Armed conflict encompasses all forms of wars and events that cause population death and displacement including civil wars, insurgencies, rebellions, or battles.

Each conflict was sorted by date and duration. Furthermore, armed conflict events in Libya, Syria, and Yemen are culled from the Armed Conflict Location &Event remix, or adapt this material for any purpose without crediting the original authors.

preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint Data Project (ACLED). ACLED collects real-time data on the locations, dates, actors, fatalities, and types of all reported political violence and protests events across Africa, Asia, Eastern, and Southeastern Europe, Latin America, and the Caribbean. It provides high quality and widely used source of real-time data on political violence and protests around the world (see https://www.acleddata.com).

To avoid misinterpretation, we focus on overall trends, not on individual events that may be poorly expressed in the time series (12) .

The collected data were analyzed using Xl-Stat2017 and PAST, version 2.17c. A simple smoother (smoothing transform with moving average as basic function; on weekly bases ) was first applied to assess beak trends of the armed conflicts and COVID-19 spread ( Accumulative number of cases, and fatalities)(13). remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

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The armed conflicts and the epidemiological manifestations of the SARS-CoV-2 epidemic in Libya, Syria, and Yemen have gone through various stages and different scenarios. Based on the data available the trajectory of conflicts and the emergence of the global pandemic by March 2020 vary greatly from each of the three countries.

The Libyan armed conflict started in 2011, with the intervention of NATO and toppling the long lasting socialist regime. Since then the country has entered into different upheavals which have been raging in 2014, by splitting control over the country between counterattack governments in east and west of Libya. The East authority had made progress from its self-declared capital in Benghazi, nominally controlling a large portion of the country and, in April 2019, launching a vicious remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint assault on Tripoli, the capital of the Western region government. Figure 1 shows 

Syria has been plugged, in a decade of armed conflict, which has also decimated Syria's health system and divided it among several fragmented areas of military control as shown in Figure 4 . The country has been torn into five different areas.

The armed opposition groups still control large parts of the northern borders including Jarablus, Afrin, Idlib Province, and Hayat Tahrir al-Sham with an remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, Hence then, there is an urgent need for quantitative assessment of the effects of the armed conflict on the spread of COVID-19 in war-torn countries.

These three countries were the last countries to report COVID-19 cases in the region. The first case in Syria was reported on March 10, 2020, followed by Libya on March 24 and lately Yemen on April 10(7). At an early stage of the pandemic, few cases were reported in each country and then increased steadily.

The conflicts continued at the same pace or become more severe during the pandemic spread particularly in Libya. Even more, most of the conflicting local remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint parties along with the regional and international actors supporting them have viewed COVID-19 as an opportunity to achieve military and political gains (18).

In Libya, only 156 cases were reported in the early months (March-July) of the epidemic which increased drastically up to 1000 cases/day by August-December. This goes parallel to the escalation of the armed conflict, which ignited on April 4, until August 2020. Similar patterns were noticed in Syria and Yemen though the number of confirmed cases in these two countries is less than that in September 2020. Assuming that the epidemic has passed its peak in transmission (21). Of the three conflicts Yemen faces the worst COVID-19 outlook, the actual number of cases is likely much higher than the reported numbers. By August, Yemen has 1,832 confirmed cases and 518 deaths.37 This death rate-greater than 28%-is five times higher than the world average (22). remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse, Our data indicate that the armed-conflict has masked the actual status of the epidemic at an early stage. This is in concordance with previous data published by Daw et al., which showed that the ongoing-armed armed conflict in these volatile regions has influenced the spread of the pandemic either by masking the actual prevalence in the armed controlling areas and accelerating the spread of the pandemic in the non-controlled region( 23).

The data collected from these war-torn countries are almost certainly a vast undercount given the authorities' chaotic response to the pandemic, especially considering the apparent concealment of cases in Sana-Yemen, Northern Syria, and East of Libya controlled territories. Furthermore, Lack of testing, population displacement, malnutrition, and poverty are the main factors making reliable figures for the incidence of COVID-19 in these countries are hard to come by.

Although this study illustrated the impact of armed conflicts on the spread of COVID-19 in these war-torn countries. A certain limitation has to be emphasized including; the sources of data collection which were based on a certain instance of gray literature that has its methodological limitations and is sometimes subject to interpretation. Further, the data used was not standardized nor validated and it should be interpreted with cautions(24,25). However, intervention programs should be based on the reality that full-blown transmission is ongoing in these countries, which do not have enough resources to respond to the impact coronavirus will have remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint on the population. Therefore, urgent national and international strategies should be implemented to combat the pandemic and its upcoming consequences (26, 27) .

This study among the first to analyze the impacts of armed conflicts on the epidemiological manifestations of the COVID-19 pandemic. Based on our data analysis, the evidence is emerging that there was a surge of armed conflict and densifying violent attacks in Libya, Syria, and Yemen. Particularly, in the first four to six months during the spread of the COVID-19 pandemic. This resulted in a hidden spread of the pandemic at the early stage, which was exacerbated lately resulting in a high number of infected cases. Suggesting a syndemic interaction between the spread of the coronavirus and the ongoing armed conflict in these countries indicates that the pandemic and its impacts are likely to evolve for years if not dealt with (28,29). Health care systems in these countries face serious challenges; as such, SARS-CoV-2 could spread rapidly through affected populations, particularly among those in the most vulnerable groups. Including injured patients, internally displaced people, prisoners, and immigrants. Hence then global interventions are needed to stop the armed conflict (as have occurred in remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

The copyright holder has placed this this version posted February 16, 2021. ; https://doi.org/10.1101/2021.02.12.21251654 doi: medRxiv preprint Libya), protection of health workers and health facilities, and enormous humanitarian support to prepare for an impending crisis (30,31).

.

No ethical permission is needed.

MD contributed solely to the conception, design, and statistical analysis. Wrote, corrected, and approved the whole paper,

The author has no conflict of interest in disclosure remix, or adapt this material for any purpose without crediting the original authors. preprint (which was not certified by peer review) in the Public Domain. It is no longer restricted by copyright. Anyone can legally share, reuse,

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