Catastrophe upon catastrophe

Between 15 and 20 patients a day are showing up with symptoms of the novel coronavirus at Dr. Ahmad Hassan’s isolation center. He has 12 beds. The center, located in the town of Izraa in Syria’s embattled governorate of Daraa, opened in March as the government worked to stall the pandemic by isolating suspected cases in key cities. Nine years into one of the world’s worst conflicts, half the country’s hospitals are destroyed or heavily damaged. Thousands of healthcare professionals have fled the country. More than 900 medical professionals have been killed.

Dr. Hassan has stayed. The orthopedist has managed his own clinic in wartime since 2015, plus he directs projects for the Catholic aid group MSJM. The charity appointed him to run the center in Izraa when it opened on March 27.

The arrival of COVID-19 in a country almost a decade at war brings catastrophe upon a catastrophe. Syria’s war has been named the worst humanitarian crisis of a generation, leaving nearly half a million Syrians dead and forcing more than 11 million—just over half the population—from their homes. International sanctions, including those of the United States, are meant to keep resources out of the hands of the government of President Bashar al-Assad but have also stymied the efforts of aid groups to address Syria’s catastrophes.

Izraa was a town of about 20,000 before the war, and it has survived with its ancient Roman inscriptions and two churches dating to the sixth century intact. The churches are considered the oldest continuously meeting churches in the world.

Dr. Hassan’s isolation center is housed in a building adjoining Izraa’s only hospital, with small rooms with large windows holding three, four, and five single beds. Each is equipped with oxygen tanks and wall-mounted fans. Surgical gurneys substitute for stationary beds in several rooms.

Like other facilities opened after the country recorded its first case of COVID-19 on March 23, it’s a stopgap measure. In the absence of widespread testing, sufficient ICU beds, and respiratory care, suspected patients are treated in the centers and released if they improve, or quarantined for 14 days to avoid transmission. Only the desperately ill are moved to hospital beds, though often a lack of ambulances and other transportation makes that impossible.

MSJM also runs a nearby quarantine center in Daraa, and through most of the war has operated mobile clinics (commonly called hospitainers because they’re made from converted shipping containers) in or near areas of fighting, most recently in Idlib where fighting between government forces and Turkish-backed militants continues. In Daraa admissions averaged eight patients per week in the beginning, records show, but spiked in June to about 14 per week.

Starting in late July, the center has seen “an explosion in cases,” said Hassan, with patients arriving sicker and needing to stay longer. By August, the center had 21 patients, and at the same time began receiving patients from overwhelmed isolation wards in Damascus.

Some come as entire families infected. Most of the cases are in their 20s and 30s, with the youngest recorded patient 8 months and the oldest 71 years. Hassan recently acquired eight ventilators—for a population numbering 1 million before the war and fewer now. Three were in use on the day we spoke by phone.

“We have not enough of everything,” he said.

THE GOVERNMENT HEADED by President Bashar al-Assad, currently controlling about 70 percent of the nation, has mobilized to coordinate a pandemic response and report cases on a daily basis: By Aug. 6, it confirmed 944 cases and 48 COVID-19 deaths. But in the Damascus region alone, health workers reported hundreds of excess deaths attributable to the coronavirus, suggesting thousands in the capital area—the country’s most stable region—already might be infected.

It’s an open secret the numbers are off, but less clear is whether the government is deliberately underreporting or simply lacks the ability to report effectively. Doctors for months have reported seeing dozens of cases per day, often recorded as pneumonia. “The official figures could be the tip of the iceberg because testing is so scarce,” warned World Vision President and CEO Andrew Morley.

The challenge to deliver test kits and other needed supplies into the country has been made harder as COVID-19 cases spike. The United States imposed new economic sanctions starting mid-June, further crippling banking and foreign transactions and coinciding with a plunge in the Syrian pound.

The central bank raised the official exchange rate from 704 to 1,256 Syrian pounds to the dollar, nearly doubling prices for most consumers. A “reference basket” of food—flour, beans, and oil for a month—has gone up 111 percent in the past year, according to the World Food Program. On the black market, where most currency flows, exchange rates are worse, plunging to 3,000 pounds on the dollar.

Also in June, the UN Security Council passed a compromise resolution limiting humanitarian access into Syria’s north to one border crossing from Turkey. The move came after Russia and China vetoed a resolution allowing two border crossings to remain. Closing the second crossing, warned the United States and its allies, deprives essential supplies to 1.5 million people—half of them children.

Aid groups are just as worried about food security as they are about COVID-19. As supplies go down, prices go up, and sanctions make it harder to move money into the country to buy products locally.

Combining those factors, the country is ripe for the virus to spread rapidly once it takes root in communities. Average Syrian family size is more than six people, and multiple families are living together or in crowded camps due to the war.

Migration across nearby borders is also prevalent. Many patients at the Izraa center work as drivers coming from Lebanon or Jordan with Syrian families who want to return. One driver from Jordan crossed into Syria carrying a family of five, arriving at the isolation center with typical symptoms—loss of a sense of smell, high fevers, coughing, and sore throats. The driver and the whole family tested positive, said Hassan, but eventually all recovered.

Mother Agnes Mariam de la Croix, the mother superior at the Melkite Greek Catholic Monastery of St. James the Mutilated, is the head of MSJM, which has successfully partnered with several U.S. and international aid groups to deliver food and medical care, including to areas of fighting. Criticized in the past for supporting the Assad regime, Mother Agnes has parted ways with Damascus over its handling of coronavirus numbers.

“They would like to appear as updated as possible and taking all precautions, but I think the numbers are less than what they are in reality,” she said. “We coped with cases in our clinics for weeks and had no PCR [tests] in Syria. We are treating ‘pneumonia’ and people are dying before we can acknowledge it is COVID-19, when in reality that’s what it is.”

Mother Agnes blamed shortages on “ongoing conflict,” but also on sanctions and border closings. “Thanks to the Lord we have not had casualties,” she told me in mid-July, “because we do not have ventilators.”

Ventilators are one of several medical items that could fall under a “dual use” category in U.S. sanctions. That means they may require a special exemption, because their parts can be disassembled and used for weapons.

The latest sanctions are layered on previous U.S., EU, and U.K. sanctions of the Assad regime. These have sparked an unusual outcry from Syrian church leaders and the international aid organizations supporting their relief work throughout the war.

Maronite Archbishop Joseph Trobji of Aleppo called them “inhuman,” and other prominent activists have been critical, too. Baroness Caroline Cox, a member of the British House of Lords and advocate for persecuted religious groups (also WORLD’s 2004 Daniel of the Year), issued a statement on Aug. 1 saying the sanctions “have caused dire humanitarian consequences” for Syrians trying to rebuild in areas retaken by the Assad regime—which includes areas of nearly all the country’s Christian population, who have been forced from Idlib and areas under Turkish and militant control.

Cox’s own relief organization, Humanitarian Aid Relief Trust, has been unable to support the Syrian Orthodox Church’s projects to rebuild in Christian areas, including Maaloula—an ancient Christian town taken by Islamic militants in 2013 but retaken a year later by the Syrian army.

Writing in the medical journal The Lancet, health experts from Oxford University and the University of Baghdad warned that applying sanctions to fragile state-run health systems during a pandemic threatens “a winter surge of COVID-19.”

THE CAESAR SYRIA Civilian Protection Act became law as part of the 2020 defense authorization bill signed by President Donald Trump at year’s end. It expands the Treasury Department’s ability to restrict economic activities of businesses, individuals, and Assad-related institutions. It can also restrict Syria’s central bank if Treasury determines it’s involved in money laundering. And it can be applied to foreigners who have dealings with the regime.

So far, Caesar Act sanctions have targeted Assad’s 18-year-old son, Hafez; relative Zuhair Tawfiq al-Assad, who leads the Syrian army’s first division; and Syrian businessman Wassim Anwar al-Qattan and nine business entities linked to al-Qattan and the regime.

“The Assad regime’s military has become a symbol of brutality, repression, and corruption,” said Secretary of State Mike Pompeo. “They have killed hundreds of thousands of civilians, detained and tortured peaceful protesters, and destroyed schools, hospitals, and markets without regard to human life.”

What concerns humanitarian groups and others are Caesar Act provisions applying to outsiders who sell or provide goods and services to anyone with ties to the Syrian government. That language has “a chilling effect,” one aid group leader told me, on humanitarian supplies to Syrian nongovernmental organizations, since they must be registered with the government and participate in state-run entities, like hospitals. Such groups may apply to the U.S. Treasury Department for exemptions, but “the process is opaque,” he said, speaking on condition that he not be named for security reasons.

The European Commission and the Treasury Department have produced written guidance for humanitarian exemptions, guidance “that can be fine-tuned to protect humanitarian efforts,” said David Adesnik, a senior fellow at the Foundation for Defense of Democracies, who favors Caesar Act sanctions.

“Critics of Western sanctions tend to miss the big picture,” Adesnik wrote in a paper published in June. They focus narrowly on deprivation “without also mentioning that Western governments have sent billions of dollars of humanitarian assistance to Syria each year.”

According to USAID, the United States has provided $10.6 billion since 2012, which includes funds to the United Nations and aid to Syrian refugees living outside their country. Such aid, Adesnik said, “addresses the need of civilians, while sanctions seek to deprive the regime of revenue it can direct to military offensives, offshore bank accounts, or other undesirable uses.”

Caesar Act sanctions won’t affect UN relief and development work, while curtailing the work of smaller NGOs and forcing them to navigate onerous legal hurdles. While its provisions have bipartisan support in Washington, on the ground in Syria the new sanctions regime appears another muddled example of Western intervention with unclear objectives.

Under the Barack Obama administration, the United States countered the Assad regime while funneling arms into Syria that ended up in the hands of al-Qaeda-­linked groups and ISIS. Then President Obama called for a campaign to defeat ISIS.

Under Trump, the United States focused more narrowly on dislodging ISIS (a goal shared by Assad). But Trump also permitted Turkey’s occupation of Syrian territory in the north at a time when Turkey has been training and deploying militant units that include ISIS and al-Qaeda fighters.

The now-radicalized Free Syrian Army—with tacit support from Obama and now Turkey—has carried out terror attacks against Christians, Kurds, and Yazidis, displacing tens of thousands in the northeast, in Idlib, and across the northwest.

Nine years into the war with civilians trapped in these proxy battles, points out Cox, the goal of cutting off Assad so his regime will fail has itself failed. Assad has survived, thanks largely to firepower from his allies, Russia and Iran. Russian forces lend crucial air support (securing a U.S. agreement to share coordinates under Obama) that allowed Assad to retake areas he’d lost to the Free Syrian Army, including Daraa in 2018.

The Syrian army for years has had ground-level support from Iranian commanders. Israeli intelligence repeatedly sighted Gen. Qassem Soleimani—the Quds Force commander killed in a U.S. airstrike in January—in Daraa and elsewhere during fighting.

Dr. Hassan has lived through those battles, though a brewing insurgency afflicts the area even now with kidnappings, assassinations, and attacks on government installations. As the COVID-19 beds fill, he returns home only occasionally and often sleeps in the hospital.

When I ask him what’s the hardest thing at the moment, he replies, “Everything. People wait too long to come for care, and they are very sick. We don’t have enough medicine ever, enough equipment or devices. We need emergency cars or ambulances. We need more tests. When I look to the future, I worry. But for now, it’s OK.”