1. Key Developments
a. COVID-19 Cases
Reported cases have been rapidly increasing over the past few months in all areas of Syria.
By 30 September about 3,000 total cases had been reported throughout the country. This number has since increased by more than 800% to reach a total of 27,500 reported cases as of 20 November ( MoH GoS, WHO , AANES ). 7,100 of these were reported in GoS-controlled areas, mostly in Damascus and Aleppo governorates ( MoH GoS ). 13,800 of the cases were in the northwest, mostly reported in Idlib governorate, representing a four-fold increase in a month ( OCHA 18/11/2020).
6,500 of the cases were in the northeast, mostly in Al-Hassakeh, Ar-Raqqa and Aleppo governorates (NES Forum 05/11/2020; OCHA & WHO 09/11/2020). Increased cases were also reported in schools following their reopening in September and in camps, with 8% of all cases in the northwest reported in displacement settings and cases confirmed in 5 locations in Al-Hol camp in the northeast ( OCHA 18/11/2020; NES Forum 05/11/2020).
Cases are greatly under-reported, due to limited testing capacities, social stigma and government pressure
In northwest Syria, the recent increase of cases is in part a result of increased testing capacity, with two additional active laboratories since October. Nonetheless, test positivity rates were significantly high at 42% in northwest Syria up to 09 July and 42% in northeast Syria as of 03 November ( OCHA 21/10/2020, AANES). Testing rate is still far below what would be required to more accurately detect infection prevalence. Testing capacity varies across the areas, but on average are between 500 and 1,000 daily tests, compared to 12,000 daily tests in Lebanon ( MedGlobal 14/10/2020) with less than half of the population. Health authorities still struggle to keep up with the spread of the epidemic and significantly scale up their testing operations. Testing kits stock in the northeast are projected to be in short supply by the end of 2020.
The reluctance of many civilians to get tested also contributes to under-reporting. Issues with social acceptance of those infected and fear of stigmatisation, or even bullying, by the community further prevents people from seeking a test or treatment ( Enab Baladi 13/11/2020, Al Jazeera 05/10/2020). Many now consider COVID-19 “shameful”, and hold COVID-19 patients responsible for their infection because they did not adhere to protective measures ( Enab Baladi 13/11/2020). Social stigma and patients’ reluctance to go to hospitals mean that probably significant numbers of people with symptoms are not seeking care or are being treated at home, leading to further difficulty in ascertaining the true scale of the epidemic, as well as increasing the likelihood of such patients to develop more severe symptoms, decreasing their chance of survival ( OCHA & WHO 29/10/2020). In GoS-held areas, fear and deep distrust of state institutions are also driving people from reporting symptoms or seeking care, as patients refuse to go to public hospitals ( Enab Baladi 13/11/2020).
Considering the limited number of tests being performed in Syria and the scarcity of accurate epidemiological data, it is highly likely that cases are not being detected and that the actual number of cases and deaths far surpasses official figures. Official statistics show a rapid increase in cases, but the high positivity rate and death reports suggests that the true scale of the epidemic is extremely underestimated. Some estimated the true number of cases around 110,000 just in the capital in September ( The Conversation 17/09/2020).
Further increases in cases likely in the coming months
As 59% of the population in the northwest are internally displaced ( HNAP 11/08/2020), and many living in overcrowded settlements ( REACH 19/09/2020), the additional contagion potential is very high, and will soon be compounded by the risks posed by the winter season. The rapid increase in cases is likely to continue to rise in the coming months as more people will spend more time in overcrowded enclosed spaces. Already, overcrowding, inadequate shelter and poor access to basic services make it nearly impossible to properly adhere to physical distancing or other public health precautions and put IDPs at a greater risk of COVID-19 infections ( A l-Araby 20/11/2020, Human Rights Watch 15/10/2020).
The Ministry of Health of the Syria Interim Government in the northwest estimated that around 64,000 people are at critical risk of infection ( The Syria report 14/10/2020). In the northwest, around 40% of the adult population is estimated to have comorbidities and around 76,000 people are over 60 years old. Both factors could lead to increased risk of COVID-19 and poorer outcomes ( MedRxiv 07/05/2020). Nationally, 1.8 million people are over 60 ( HNAP 11/08/2020).