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A health worker with a face mask walks inside a hospital, as hospitals enforce a series of measures to prevent the spread of the coronavirus disease (COVID-19), in Damascus, Syria March 19, 2020. © 2020 Reuters/Omar Sanadiki

(Beirut) – Syrian authorities are failing to protect health workers at the front line of the Covid-19 pandemic in government-held territory, Human Rights Watch said today.

Doctors, aid workers, and civilians, including in government-held Syria, told Human Rights Watch that the country is overwhelmed, with hospitals beyond capacity, health workers facing serious shortages of personal protective equipment (PPE), and with many of their colleagues and relatives dying after suffering Covid-19 symptoms. The Health Ministry said that 76 health workers had tested positive for the virus as of August 21. A total of 2,765 confirmed cases and 112 related deaths were reported by August 31, 2020. However, evidence suggests that the numbers across the country could be significantly higher.

“It is bewildering that as the obituaries for doctors and nurses responding to the Covid-19 pandemic pile up, official numbers tell a story at odds with the reality on the ground,” said Sara Kayyali, Syria researcher at Human Rights Watch. “The Syrian government has already engaged in crimes against humanity against its own people, so its lack of concern for the health of its front-line workers during a global pandemic is sadly no surprise.”

Human Rights Watch interviewed three doctors, one nurse, two aid workers, and two experts, reviewed social media posts by people or pages considered reliable sources, and collected reporting by reliable third parties to assess discrepancies in the Syrian government’s reporting on its own response to the Covid-19 pandemic.

Those interviewed said that shortages of adequate protective equipment and restricted access to oxygen tanks are most likely contributing to deaths among Syria’s health workers and the wider population. Health workers said that testing, oxygen, and basic medical care are available only to those who can afford it, violating the fundamental right to equal and affordable access to health.

The World Health Organization (WHO) and other organizations with a health mandate should publicly insist on expanding testing capacities and transparent and accurate reporting on numbers of Covid-19 cases and equitable distribution of sufficient personal protective equipment to health workers throughout the country, including rural areas, Human Rights Watch said.

An independent outlet, Syria-in-Context, has estimated that there have been at least 85,000 cases of Covid-19 in the Damascus region alone. It based its conclusions on obituaries posted online from July 29 to August 1, satellite imagery of cemeteries, and interviews with doctors, and then extrapolated them using a model created by the Imperial College London model for Covid-19 transmission. The United Nations has indicated that it is unable to confirm or verify reports of additional numbers of cases.

Residents said their neighbors and relatives were falling ill or dying after exhibiting symptoms consistent with Covid-19, including high fever and severe respiratory distress. They said that their relatives who had attempted to go to a hospital or clinic were turned away for lack of capacity.

Nurses, doctors, and aid workers who work in hospitals or support their operation from outside Syria said that major hospitals that are prepared to deal with Covid-19 cases, such as al-Assad University Hospital, have exceeded their capacity, and other hospitals do not have the necessary infrastructure, citing a lack of availability of oxygen canisters, ventilators, and beds. Front-line workers said they do not have the necessary protective equipment, training, or protocols to treat complications from Covid-19.

On August 16, a list of 61 health workers who died in the period since Covid-19 was first detected in Syria was circulated on social media. Human Rights Watch was able to verify the deaths of 33 doctors on these lists by collecting obituaries posted by the Damascus Medical Association, all of which indicated that they died while responding to Covid-19. Two Syrian doctors said they personally knew at least some of the doctors on the list. The official total numbers of deaths from Covid-19 for the entire population at the time was 64. The death toll among health care workers calls into question whether the Syrian government’s reports are representative or accurate.

The deaths that are reported in official government obituaries are primarily members of the elite, such as heads of hospitals or former teaching doctors, doctors said. Doctors interviewed estimated that the number of deaths among front-line doctors and nurses is most likely much larger due to the failure to account for health workers in rural areas, and their own knowledge of doctors and nurses who have died.

While the exact causes of underreporting are difficult to discern, several factors play a role, including the government’s restrictions on informing aid workers of test results early on and a lack of widespread testing despite pressure by healthcare organizations to expand testing capacities. Human Rights Watch has previously documented the authorities’ refusal to collect and test Covid-19 samples in northeast Syria.

As a UN agency, WHO can only operate with the government’s approval, and the government controls reporting, a well-informed source said. Credible data on the number of Covid-19 infections is essential for a more robust response, Human Rights Watch said.

Access to PPE and basic medical care also appears to be discriminatory based on status and wealth. As of August 21, WHO has provided the Syrian government with 4.4 million items of PPE, including medical and respirator masks, gloves, gowns, shoe covers, and alcohol hand-rubs. However, doctors and nurses operating in government-held areas said that there are severe shortages of supplies, particularly in rural areas.

“Every Thursday, authorities would deliver 50 disposable surgical masks that are supposed to last for the week,” said a nurse in a rural area. “I ration them so that I use one mask per shift, when I am supposed to change the masks for every patient.” She and two other doctors said that relatives buy them protective personal equipment, as well as reliable drugs to treat the symptoms of Covid-19.

A doctor leading a program that imports protective equipment and oxygen tanks confirmed that it is raising funds and sending oxygen canisters, but not through the Syrian government, “because it can’t be trusted.” Human Rights Watch has previously documented the authorities obstructing humanitarian aid, including through restrictions on access, discriminatory distribution, and insistence on problematic partnerships.

Two aid workers said that in some cases, supplies were shipped to areas held by the Syrian government, but that those supplies did not make it out of the Health Ministry warehouses. On May 8, a member of the Finnish-Syrian Friendship society said that a shipment of medical supplies to Sweida, a governorate in southwest Syria under government control, has been held up for 14 months and remains in the ministry’s warehouses.

One doctor said that tests, protective equipment, and oxygen masks are available but that “how well-off you are financially determines if you get tested and if you get the drugs you need.” The doctor and a nurse said that an oxygen tank costs as least SYP700,000 (official US$557/black market $321), while ventilators cost approximately $12,000. Such costs are prohibitive for residents of a country where 83 percent of the population is below the poverty line and facing a deepening economic crisis.

The Syrian government has an obligation to protect health workers and patients in health facilities from infection and should provide health information and adequate protective clothing and equipment to minimize risk of infection. This means providing health workers and others involved in the Covid-19 response with appropriate training in infection control and with appropriate protective gear, across areas under its control or where it controls access.

On August 27, Human Rights Watch wrote to WHO, with its findings and recommendations. On September 1, WHO responded, indicating that it is “providing test kits, protective gear, and supplies needed to treat COVID-19 patients,” and that in July 2020, they recommended that the Syrian government increase testing and expand laboratory networks; strengthen infection prevention, including increasing availability of PPE to health workers; reinforce hospital capacity and community awareness. It remains unclear whether the government has adopted the recommendations made by WHO, and whether WHO has addressed the potential disparity in provision of health care across urban and rural areas, as well as the lack of training and support that healthcare workers reported.

The government should publicly state its commitment to increasing testing capacities across the country, including in rural and nongovernment-held areas, and take concrete steps to facilitate the development of more testing centers, that are equally accessible. If the Syrian government fails to act decisively, WHO, and other organizations with a health mandate, should make public their insistence on expanding testing capacities and transparent and accurate reporting on Covid-19 infections and related deaths, and clarify the specific reasons for the failure to report numbers accurately, as well as the challenges with distributing adequate amounts of PPE to health workers in a nondiscriminatory manner, including the imposition of government restrictions or their refusal to adopt WHO recommendations.

Given the long history of aid diversion, including of medical supplies, by the government, WHO should insist on delivery through independent organizations. Donors should actively press to UN and international groups operating in Damascus to collectively bargain with the Syrian government to allow for decentralized testing and equitable distribution of protective equipment.

“The Syrian government has essentially left health workers to fend for themselves in fighting the Covid-19 pandemic and abdicated its responsibility to take the steps needed to save lives,” Kayyali said. “For once, it needs to put Syrian people first, and provide all health workers with adequate resources and protective equipment and issue accurate and transparent information.”

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