Reaching the Hard-to-Reach: A Look at the Zogra Camp in Syria

By Emma Ackerman, MedGlobal Communications & Advocacy Intern

Conflict in Syria has brought 10 years of near constant threats of violence, destruction of health infrastructure, ongoing violations of international humanitarian and human rights law, poverty and economic crisis, and widespread displacement. The UNHCR reports that 6.7 million internally displaced people (IDPs) living in Syria will need humanitarian aid in 2021, a 600,000 person increase from 2020. Ongoing conflict and destruction of critical infrastructure has caused one the world’s worst, most pervasive humanitarian crises, which has only worsened during the COVID-19 pandemic.

MedGlobal works in Syria to address health and humanitarian needs, and has recently extended operations to support health programs in the Zogra IDP camp. Zogra is located 27 km (or 17 miles) from Jarablus, a town in the Aleppo province of northwest Syria – very close to the Turkish border. The camp first opened in March 2017 to receive residents of the al-Waer neighborhood of Homs City who were forcibly displaced after years of siege and armed conflict. Most had already been displaced within Homs multiple times. Zogra later received waves of IDPs from Eastern Ghouta and Idlib. Despite reports that Zogra was prepared to receive IDPs, the first to arrive found a ‘catastrophic situation’ where most had to spend the first night either on the ground or in the buses they had arrived in. Tents were delivered soon after, but bathrooms and water sanitation services remained nonexistent. According to a resident of Zogra, “If the pain and oppression had a voice, you could hear it in the Zogra refugee camp north of Aleppo.”

From a geographical perspective, Zogra is one of the most difficult camps to reach, resulting in a massive unmet humanitarian need among IDPs in the camp. MedGlobal Turkey Country Director Dr. Hala Alghawi recently travelled to Zogra camp on a trip that took over three hours. Lack of safe roads, lack of available transportation, and expense of travel to the camp from nearby locations such as Jarablus and Azaz contributed to the difficulty of travel to this hard-to-reach area. She estimates that as of June 2021, 15,000 people (or around 3,000 families) are living in Zogra camp. A recent needs assessment of Zogra camp conducted in August 2020 echoes many other accounts of dire humanitarian needs in Zogra, including: insufficient and infrequent distribution of food, unavailability of health care services amid increasing need, chronic unemployment, poverty, scarcity of fuel for heating & cooking, shortage of weather insulators, and lack of warm clothes. Insufficient water sanitation and sewage systems are still grave health concerns in Zogra. The toilets are essentially open pits that facilitate the spread of diseases and epidemics, especially during summer months. Food security remains one of the most pressing needs among IDPs in Zogra. In addition to the 2017 cholera outbreak, 10 cases of poisoning in children due to unclean water were reported in 2019. Despite the acute need for more comprehensive health care, health facilities in Zogra are rudimentary, consisting only of a single pharmacy, pediatric clinic, gynecology clinic, and general medicine clinic. These primary care services are the only form of medical care available in Zogra. If specialized services are needed, residents must make the long, arduous, and expensive journey into Jarablus, where they will then likely be referred to cities such as Al Bab and Azaz, another two-hour trip. Vulnerable populations – such as pregnant women, the elderly, chronic disease patients, people with disabilities, critical care patients, ophthalmic cases, cardiology cases, and other subspecialty needs patients – require the most specialized care, and are therefore at an even greater risk for negative health outcomes during displacement. While observing these hardships, Dr. Alghawi shard a poignant reflection:

“It is not the Syria which I grew up in years ago. It was emotionally very painful to see my people, children and elderly, live in these inhumane circumstances. They have to adapt and fight for a better future. They seek safety and dignity but unfortunately they got the [bare] minimum.”

Existing aid programs and health care services have lessened the suffering of IDPs since arriving in Zogra, but are very far from addressing the many pressing needs of this forgotten population, and do not erase the needless suffering that has already occurred. Dr. Alghawi has highlighted some of the largest gaps in current services:

Medication supply shortages, especially for chronic diseases
Lack of specialized health services less than 1.5 hours away from Zogra
No services or centers for children with learning disabilities
No mental health & psychosocial support (MHPSS) services
No sexual and reproductive health (SRH) awareness or education programs
No rehabilitation centers for physical and mental disabilities

MedGlobal operations in the hard-to-reach Zogra camp aim to build capacity in existing health facilities and address the needs of the most vulnerable. Just this past week, MedGlobal donated a six month supply of medication for acute pediatric cases and provided 650 patients suffering from non-communicable diseases with vital medications. Dr. Alghawi passed on this message from a field manager in Zogra Camp:

“May God reward you and bless you for the great effort made to visit the camp. You made their hearts happy and they felt that someone remembers and takes care of them.”

As of June 1, only 12% of the $628.6 million requested by UNHCR for the 2021 Syria Operation has received funding. The world cannot forget about the displaced people in Zogra. There are numerous opportunities for implementation of advocacy activities and health programs in Zogra, and even a small amount of funding will make a noticeable difference in the quality of care available to Zogra’s most vulnerable IDPs.

Challenges to COVID-19 Vaccination in Syria

By Andrew Moran, MedGlobal Policy & Advocacy Intern.

On March 15, the humanitarian crisis in Syria will enter its eleventh year. A decade of violence and devastation in Syria has led to the deaths of hundreds of thousands of Syrians and engendered the largest refugee crisis in the world. More than 5.6 million people have fled Syria, including 70% of the country’s health workers. Among those that remain, 6.6 million Syrians are internally displaced. The destruction of infrastructure and interruption of services across the country has exacerbated the humanitarian crisis and now 13.1 million people are in need of some form of aid.

The outbreak of COVID-19 across Syria has created new challenges and put additional strain on health systems that have reached their breaking points. Half of all health infrastructure in Syria has been damaged or destroyed from the conflict which, when combined with mass displacement, limited testing capacity, and lack of coordination among local authorities, has hindered efforts to contain the spread of the virus. Though the actual number of COVID-19 cases in Syria is likely significantly greater than official figures suggest, each region has reported evidence of widespread community transmission:

Total Confirmed Cases in Government-Held Areas: 15,981 (Mar 8)
Total Confirmed Cases in Northwest: 21,214 (Mar 10)
Total Confirmed Cases in Northeast: 8,689 (Mar 8)

Northwest Syria, the region with the most confirmed cases and a positive testing rate of 28%, has only nine hospitals equipped to handle COVID-19 patients. Between them, the northwest has the combined capacity of only 212 ICU beds and 162 ventilators for a population of more than four million people. In response to the health crisis, MedGlobal has worked with partners to distribute tens of thousands of personal protective equipment items and personal hygiene kits to health workers and people in need. MedGlobal has also provided 200 oxygen concentrators and 100 CPAP and BIPAP machines to health facilities and built critical health infrastructure, including two industrial oxygen generators in Idlib and Darkoush.

Syria is expected to receive its initial supply of vaccines in April through the COVAX program, enough to cover 3% of the population. The Syrian government, which will control the national distribution of vaccines, has not clarified whether it will include certain areas, such as those not under its direct control, in its vaccination plan. Concerns over vaccine access have led local authorities in northwest Syria to submit their own formal request to COVAX for a direct supply of vaccines. According to the self-styled regional government, the WHO will provide 1.7 million doses of AstraZeneca vaccine to the northwest starting in late March. Unlike the northwest, which continues to have access to aid through a UN sanctioned border crossing, the northeast is entirely dependent on the Syrian government for aid delivery. The northeast has no mechanism for receiving vaccines in the event that the government decides to delay or halt vaccine delivery.

Access to vaccines is critical, but technical, logistical, and social challenges may prevent successful implementation of vaccination campaigns. Many areas of Syria lack the necessary equipment and continuous access to electricity required for storing certain types of COVID-19 vaccines. In the northwest, where half the population is displaced, identifying and reaching individuals from priority groups and following up with a second dose in three to four weeks will be difficult. Many displaced Syrians lack formal identification and repeat displacement events, such as the massive flooding that affected more than 67,000 IDPs in January, will complicate tracking efforts. Combating widespread misinformation and entrenched stigmas surrounding COVID-19 and vaccines is also necessary for people to participate in vaccination campaigns. In preparation for the arrival of vaccines, local and international health organizations are working together to set up 93 vaccine distribution centers and mobile units in northwest Syria. While this is critical for building capacity, overcoming the other challenges and ensuring the safety of health workers will ultimately require greater support for the northwest, and the rest of Syria, to achieve herd immunity and overcome the COVID-19 crisis.

Syria: Displacement in the Last 4 Years

As the year 2021 gets closer, so does the tenth anniversary of the conflict in Syria, which has led to over 500,000 deaths, destroyed the country’s infrastructure, and displaced nearly 13 million people from their homes, leading to the world’s largest displacement crisis. The health sector in particular has been decimated – as much as 70% of the health workforce has been displaced out of the country, there have been more than 600 attacks on health facilities, and at least 923 medical personnel have been killed, over 90% by Syrian government attacks. The targeting of healthcare has been used as a strategy of war from the beginning days of the conflict. Attacks on civilian areas coupled with the destruction of the health facilities and lack of medics that would treat them has been a central driver of overall displacement.

Currently in Syria, there are at least 6.2 million people, including 2.5 million children, internally displaced. From April 2019 through March 2020, an aerial and ground offensive in northwest Syria – during which attacks on civilian areas including schools, hospitals, and markets was frequent – led to the death of at least 1,600 civilians and the forced displacement of around 1.4 million people. Many of these internally displaced persons (IDPs) had been displaced several times over. These figures are just the latest displacement statistics – based on research from the Internal Displacement Monitoring Center, there have been millions of people displaced internally each year over the last four years:

2017: 2.9 million new displacements
2018: 1.65 million new displacements
2019: 1.85 million new displacements
2020: 1.47 million new displacements (through June 2020)

In addition to the mass internal displacement, an additional 5.57 million Syrians are displaced outside the country as refugees. This number has grown significantly from the 4.8 million Syrian refugees registered with the UNHCR at the end of 2016. For the vast majority of refugees, conditions for a safe return to Syria do not currently exist, and the protracted nature of the refugee crisis persists.

At the same time, in the U.S., policies around refugee resettlement have been drastically scaled back over the last four years. The U.S. has historically been the global leader in refugee resettlement, especially since the passage of the 1980 Refugee Act. However, while the world faces the highest levels of displacement on record, refugee admissions to the U.S. have dropped to a historic low over the last four years.

In 2016, the Presidential Determination for refugee admissions was 85,000. Each year since then, the Presidential Determination has hit a new historic low, with a FY2021 refugee admissions cap of only 15,000. During this administration, there have been numerous policy changes – from the refugee admissions cuts to three Presidential Executive Orders denying admission to refugees from specific nationalities, most notably Syrians – dismantling the U.S. refugee resettlement infrastructure.

For Syrian refugees, who make up more than 27% of refugees under the UNHCR’s mandate, the effect in this policy shift has been particularly pronounced. A total of 22,138 Syrian refugees have been admitted to the U.S. since 2012. However, since 2016, the United States has only resettled 7,668 Syrian refugees, a sharp decline from the 12,587 who were resettled in 2016 alone. In 2020, only 481 Syrian refugees have been resettled in the U.S., just over 3% of the 2016 total.

Graph of Syrian Refugees Admitted to the United States

Moving forward, it is critical that the effects of the conflict in Syria and the displacement crisis be addressed at all levels – in Syria, the region, and globally. MedGlobal is proud to have partnered with several Syrian and refugee-led organizations supporting healthcare in Syria and the region, including Violet Organization, Rahma Relief, UOSSM, and Multi-Aid Programs (MAPs). During the COVID-19 pandemic alone, MedGlobal has worked with partners to distribute tens of thousands of personal protective equipment (PPE) and personal hygiene kits; support a 150-person quarantine center in Darkoush, which provides food, hygiene, housing, and daily medical checks for displaced families; and build critical infrastructure, most notably industrial oxygen generators in Darkoush and Idlib City to support COVID-19 patients and others who need breathing assistance. Additionally, in August MedGlobal began to provide 200 oxygen concentrators and 100 CPAP and BIPAP machines, or non-invasive ventilators to help people who are suffering from severe COVID-19 symptoms breathe, to cities throughout Syria in partnership with local independent NGOs.

It is critical that governments and stakeholders step up to support displaced Syrians through increased support and protection programming for displaced civilians inside of Syria, service provision and ample rights for refugees displaced regionally, and increased resettlement of refugees at a global level, including the United States. Each year, the Presidential Determination should be put forth to at least 95,000, in line with historic averages. Direct funding for local and refugee-led humanitarian and civil society organizations should be increased. The displacement crisis for Syrians in the country and refugees outside of the country is far from over, and these communities must not be forgotten.

The Escalating COVID-19 Crisis in Syria: Humanitarian and Health Update

The COVID-19 crisis in Syria is reaching a tipping point as hospitals become overwhelmed, testing remains limited, and cases are surging across the country. The impact of the pandemic is adding to an already dire humanitarian situation in Syria, nine years into an emergency conflict that has led to staggering levels of death and need inside the country, decimated the country’s infrastructure, and led to the world’s largest displacement crisis.

On October 1, MedGlobal hosted the webinar “The Escalating COVID-19 Crisis in Syria: Humanitarian and Health Update” focusing on the COVID-19 crisis throughout Syria, giving a picture of the crisis, response, and key needs in different governorates. Speakers gave insights into the COVID-19 response and updates from medics inside Syria. Below are the highlights from each panelist’s remarks.

Dr. Zaher Sahloul

President and Co-Founder of MedGlobal

“No one knows what the real COVID-19 numbers are, the official numbers are only the tip of the iceberg.”

“This is the only country where I’ve heard that patients need to purchase their own oxygen and ventilators to be treated at home because hospitals are not accommodating these patients. Because 8 out of 10 Syrians are below the poverty line and cannot afford this equipment, many people have died without being treated, they suffocated to death inside their homes.”

At least 50% of healthcare providers have fled due to the targeting of hospitals and health workers. Health infrastructure has been destroyed, especially in the northwest, but even in government-controlled areas hospitals have been poorly managed and faced growing shortages of specialists.
The Syrian government has only reported roughly 4,000 cases of COVID-19 and 200 deaths. However, physicians and experts in Syria believe that the actual number of cases is much higher. Some medical leaders in Syria have estimated that the actual number of COVID-19 cases may be over 110,000 in Damascus alone.
Part of the problem is that testing in Syria remains extremely low. Only 35,000 tests have been conducted in government-held areas since the start of the pandemic. In comparison, Lebanon and Jordan are conducting 12,000 and 16,000 tests per day respectively and have much smaller populations than Syria.
A dire lack of resources has also exacerbated the crisis. Personal protective equipment (PPE) is essential for the safety of both health workers and patients, but many physicians are now having to buy their own. This has contributed to an increase in infections among doctors and according to the Healthcare Union in Syria, at least 61 health workers have died from the virus. As a consequence, some doctors are reluctant to treat patients with COVID-19 and private hospitals closed their doors to protect their other patients.
Each urban area has only 2 to 3 hospitals to treat COVID-19 patients. In Damascus, there were only 2 hospitals dedicated to treating COVID-19 patients, leading to long lines and people dying in crowded emergency rooms. For many Syrians, accessing treatment requires them to purchase their own oxygen concentrators and ventilators – an insurmountable barrier in a country where eight out of ten people live in poverty.

Dr. Naser Almhawish

Surveillance Coordinator for the Early Warning Alert and Response Network (EWARN) of the Assistance Coordination Unit

“To purchase a few thousand N95 masks… we had to wait more than one month.”

“The absence of good governance in the field is a huge issue because you do not have accountability.”

The situation in northwest Syria has been developing rapidly in the last month.
We can divide the COVID-19 response in the northwest into two stages: before the first cases were identified in July, and since COVID-19 cases have been confirmed. The closure of the borders around northwest Syria isolated the area and initially delayed the spread of COVID-19. Now, coordination and surveillance is essential for identifying gaps in the response and efficiently allocating resources.
Expanding laboratory capacity for testing is critical, as is protecting health workers. Nearly 30% of confirmed cases are among health workers and the quarantining of staff for two weeks has devastating consequences for the health sector.
Between July and August, there were only around 100 confirmed cases total in northwest Syria. In September, there have been 990 cases confirmed, and we know this is not all.
Major challenges include the displacement of people, limited lab capacity, overwhelmed staff and shortages of healthcare providers, coordination issues and weak governance, and stigma which lead to people denying potential symptoms and prevents people from getting tested.
The lack of PPE is greatly affecting healthcare providers. It’s also important to note that other safety and protection issues continue to affect healthcare providers, such as attacks on hospitals and airstrikes.

Hazem Rihawi

Senior Programs Manager of the American Relief Coalition for Syria (ARCS)

“This is the time now to increase the funding and the support for humanitarian responses coming into the northwest, the northeast, and government-controlled areas.”

“The health systems even in developed countries were struggling to be able to control this and you can imagine in a conflict zone like Syria it will be a further issue.”

Research from the NWS Modelling Team at the Covid Modelling Consortium estimates that the COVID-19 peak will happen in mid-November if limited interventions happen.
There are only 75 hospital beds in the northwest available for COVID-19 patients, which is much lower than needed. Hospitals in the northwest are already at 90% capacity.
The time is now for countries like the United States and other stakeholders to increase humanitarian funding to all areas of Syria before the number of cases peaks in the coming weeks.

COVID-19 Response Coordinator

Northeast Syria Forum

“Social stigma continues to be a significant issue. People tell us that they don’t ring the hotline because they don’t want the neighbors to see an ambulance… they don’t want the rumor to get out that they might have the virus.”

“Just because we have beds which are currently operational does not mean that the quality of care is necessarily assured.”

“The impact of the UN Security Council Resolution 2533 renewal, or non-renewal you could say, is that to have a predictable supply line in northeast Syria, we do require multiple modalities, whether that is UN cross border shipments under a Security Council resolution, NGO local procurement, NGO cross border procurement, or cross-line assistance from Damascus. We need this because we know that any one of these pipelines can break down.”

As of September 30, there have been 1,670 confirmed cases of COVID-19 in northeast Syria, including 67 deaths and 437 recoveries. At least 200 health workers are in self-isolation or quarantine and 10 health facilities have closed either a section or entirely. There is a gap of 818 hospital beds and 236 intensive care unit beds and virtually all patients who have been ventilated have died. Despite the crisis, which is on track to worsen significantly, there are no movement restrictions or lockdowns in place and there is minimal adherence to personal preventative measures.
One of the key challenges that needs to be addressed in the northeast is the low levels of risk perception among the population. It is important to remember that over the last nine years, the people living in this part of Syria have experienced immense hardship from the Syrian conflict, living under ISIS, and dealing with an economic crisis. Civil leaders have downplayed the danger of the virus and stigmas around COVID-19 keep people from reporting symptoms and seeking treatment. There are low levels of hospitalization as people are dying in their homes rather than seeking medical care and those that do often wait until they are at advanced stages of the virus.
The closure of the Al Yarubiyeh border crossing into northeast Syria has further intensified the crisis by disrupting supply chains. PPE in hospitals is being washed and reused and some health facilities have instituted policies against using PPE unless the patient is confirmed to have COVID-19. Supplies for conducting testing are also in great demand and there is concern that testing capacity will fall to zero by the end of the year.
Key needs for managing the COVD-19 crisis include high levels of funding through 2022 and improved coordination between health facilities and different levels of governance.