Voices from the COVID-19 Pandemic: “Within 20 Days of the First COVID-19 Case, our Health System will Collapse.”

A Q&A with Dr. Munther al-Khalil, Head of Idlib Health Directorate in northwest Syria.

An orthopedic surgeon by specialty, Dr. Munther al-Khalil is head of the Health Directorate of the northwest Syrian governorate of Idlib, which has been under months of bombardment by Syrian government and Russian forces intent on eliminating the last opposition stronghold in the country.  The Idlib Health Directorate focuses on health governance and public health services in areas where the Syrian government has suspended such services, providing services like forensic medicine, vaccinations, and medical waste management.

On April 5, 2020, PHR contacted Dr. al-Khalil, now based in Gaziantep, Türkiye, for his assessment on the situation in Syria’s northwest as the COVID-19 pandemic looms. Dr. al-Khalil describes the state of the area’s health care system, its readiness to confront the COVID-19 pandemic, and the possible consequences of a rapid spread of the disease. Below is an extract from the interview.

PHR: How would you describe the condition of the health sector in northwest Syria today?

Dr. al-Khalil: Between April 2019 and today, the [Syrian] regime and Russia have targeted 67 medical structures in northwest Syria. In our assessment, Russia was the primary perpetrator. In most of the attacks on health facilities, we lost equipment, medical personnel – a lot of resources. We were only able to transfer a small amount of equipment to [safety in] the north. Before this latest campaign, the area saw hundreds of attacks on hospitals and clinics, but they weren’t as brutal as the ones we’ve seen more recently; they didn’t seem as bent on clearing entire areas of medical services. Since April 2019, what we have seen is not merely a series of attacks on individual health facilities, but a campaign to totally destroy health infrastructure.

These attacks severely degraded our capacity to provide care. The state of the health care system is reflected in the resources at our disposal. Today, in Idlib, we have 107 ICU beds and 47 ventilators and there are over four million people living in the area. And I don’t have a single vacant ICU bed or ventilator. If I actually repurpose these beds and ventilators to cater to COVID-19 patients, I might save a number of those patients, but others – potentially a higher number – will die [of other causes] in the process.

PHR: What are the main challenges the health sector in the northwest is facing today?

Dr. al-Khalil: The systematic assault on health facilities also coincided with a sharp fall in funding to health programs in Idlib, which weakened health governance in the area. For example, we at the Idlib Health Directorate are at the forefront of the response to COVID-19. You might be surprised to learn that the directorate’s employees have been working as volunteers for the past seven months. The last time they were paid was at the end of July 2019. Imagine that during these extremely difficult and complex circumstances, I have to lead a response to a pandemic that even the United States is having a difficult time managing, relying entirely on volunteers. 

“Since April 2019, what we have seen is not merely a series of attacks on individual health facilities, but a campaign to totally destroy health infrastructure.”

I see this as part of a politicization of funding to the area. There seems to be a lack of desire by international donors to support institutions here. Of course, there’s funding coming into the area in the form of support to individual facilities and organizations. But that doesn’t allow us to build a health system. You cannot build a health system without having a common health information database, without a drugs control system, without waste management, without a referral system. All these activities fall under the label of health governance and are receiving no funding. That’s highly problematic.

The problem is compounded by the general lack of governance and governmental institutions in the area. In other contexts, we have seen that the response to COVID-19 is not lead only by the health sector. It’s usually a shared responsibility, where the army, the police, municipalities, civil defense, and all other public institutions work hand-in-hand to create an effective response. We in Idlib do not have any of those support structures.

The weakness of the response so far, and the dip in funding, makes us think that we’ve been entirely abandoned.

PHR: How are people in Idlib dealing with the threat of COVID-19?

Dr. al-Khalil: One of the biggest challenges we’re facing when raising awareness about social distancing and self-isolation is that we’re confronted with displaced people who are telling us they don’t have homes to stay in. About 65 percent of the current population of Idlib was displaced from one area or another and we have nearly one million people living in camps. Some of these camps are hosting above four times their capacity. People come to us and tell us “we’re ten to a tent.” How do I tell that person to socially distance? In addition, people can’t afford to stay at home. They live day to day. If they stay in isolation for two or three weeks, they’ll go hungry. There’s a different kind of calculus at play here.

“The weakness of the response so far, and the dip in funding, makes us think that we’ve been entirely abandoned.”

“Stay at home” is the main prescription the world over. So, what are we to do when cases start appearing? We can’t take them into our hospitals and the very notion of social distancing or isolation is ludicrous. This is what will drive the disaster that is heading our way. 

Another challenge we’re encountering is the hopelessness that permeates the population. They tell us, “We’ve died a thousand times over. From chemical attacks, and barrel bombs, and rockets, and hunger, and torture, and freezing weather. The virus can’t do more than that.” Death has become something too familiar to people in this area and they have lost the will to resist. The Syrian regime is fully responsible for that.

PHR: What are the possible implications of COVID-19 on health workers in the northwest?

Dr. al-Khalil: The targeting of our health care has led to significant material losses. But our health workers have been hit very hard too. Some were detained, many were killed, and others left the country. Those who chose to stay behind are completely exhausted and many are starting to consider leaving. The coming period is going to be extremely challenging for them. Until now, we don’t have adequate personal protective equipment. If we see a spread of COVID-19, the majority of our health workers will become infected and we will lose many of them because we haven’t been able to provide them with the necessary gear. The consequences of losing health workers will be irreversible. There is no way we can compensate for the loss of a single doctor.

“They tell us, ‘We’ve died a thousand times over. From chemical attacks, and barrel bombs, and rockets, and hunger, and torture, and freezing weather. The virus can’t do more than that.’ Death has become something too familiar to people in this area and they have lost the will to resist.”

Imagine ten, twenty or a hundred people dying outside a hospital that just cannot give them beds, or medication, or oxygen. I can tell you, even back in the days of the regime, when we were active as doctors in Aleppo and other locations, we used to be targeted by people who thought we weren’t prioritizing their needs. The security implications for health workers of not being able to provide services will be very significant and might lead many them to decide to quit.

That being said, the volunteers who are leading the response are ethically committed to seeing it through. I work 17 hours a day and haven’t taken a day off in years. Not a Saturday, not a Sunday, not a Friday – not one day. I’m a doctor and I’ve been postponing an operation I must undergo for three years because I can’t afford to take three days off. This applies to all my colleagues here. We’re committed, but we can’t carry the whole responsibility alone.

PHR: Can you describe your plan to respond to COVID-19?

Dr. al-Khalil: Our strategy to respond to the pandemic is multi-faceted and starts with ensuring the protection of health workers. We prioritized this point because we believe that the consequences of any blow to health workers will linger well beyond the current challenge we’re facing. The second point is concentrating on delivering care to the non-critical cases, specifically those who will need oxygen and medication. Third, we intend to focus on the social aspects of prevention – primarily on raising awareness and attempting to procure and distribute facial masks, which might be the best countermeasure in our context.

Our fourth objective is raising the capacity of the health system. We are hoping to delay as much as possible the entry of the virus into the area and to flatten its spread once it does enter so that the health system is able to cope. If we can buy time and push the apex of the spread until the summer, we might be able to learn some lessons from other contexts. We might also see that those countries that are today in the midst of their own COVID-19 crises are over them and are in a better position to offer us their support. We certainly cannot bet on the virus not making its way into the area.

PHR: What is the worst-case scenario, in your opinion?

Dr. al-Khalil: All those in need of critical care, of ventilators, will die because of our inability to admit them and care for them. The proportion of patients who require oxygen therapy and medication will eventually need critical care because we don’t have the resources to treat them. Many of them will also die. Logically, if nothing changes, we might see up to 100,000 people die in the area.

I think that within 20 days of identifying the first COVID-19 case, our health system will collapse. When we have hundreds of patients in need of critical care at hospital doors, that flood will create massive social disturbances. We’re in a state of chaos here and there is a variety of armed groups – including extremist elements – in the area. Our medical cadre is completely exposed. I don’t how long the system can hold after we see the first death of a doctor as a result of the virus or a security incident linked to it.  

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