A s Europe deals with the coronavirus pandemic that has crippled healthcare services on an unprecedented scale, countries in the Middle East already demolished by war are bracing themselves for disaster.

Doctors and health officials tell The Independent in over a dozen interviews across Syria, Yemen and Libya that they cannot halt the spread of the deadly coronavirus, and that healthcare systems are completely “open and vulnerable” to the impending crisis.

They fear millions of vulnerable people are at risk of death in places where years of conflict have destroyed healthcare systems, severed supply lines and allowed famine and diseases like cholera to sweep through the populations.

Preventative measures like social distancing and lockdowns are impossible for many who fled the frontlines and are now living in crammed displacement camps or temporary housing with little access to water or sanitation products to wash hands.

SYRIA: Latest deaths just the ‘tip of the iceberg’

As Syria enters its tenth year of war, the country is no closer to finding a peaceful solution. At least 11 million people in the country already need humanitarian assistance to survive, while almost eight million people do not have reliable access to food.

Physicians for Human Rights (PHR) say that since the start of the 2011 civil war, there have been at least 595 documented attacks on over 300 hospitals across the country, mostly perpetrated by the Syrian government and its allies Russia and Iran.

Much of that destruction has not been repaired, particularly in former opposition strongholds: only half the country’s medical facilities are working, according to the World Health Organisation (WHO).

Syria recorded its second Covid-19 death on Monday, a number that has been described by the United Nations as the “tip of the iceberg” as it may be much lower than the true figure.

Medics across the country have also told The Independent there are many more sick that have not been reported.

While Damascus has rolled out nightly curfews, partial lockdowns and testing to combat the disease in regime-held areas, it has been harder to enforce these measures in the rest of the country.

Northwest Syria: ‘Primed for the health disaster that is about to unfold’

An area of critical concern is the country’s opposition-held northwest. Idlib and northern Aleppo are home to four million people, a million of whom were displaced last year alone in the regime’s latest offensive on the rebel’s final holdout. Many civilians live in overcrowded, unhygienic camps.

PHR’s Rayan Koteiche said there had been at least 40 confirmed attacks on hospitals since April 2019.

“The area is open, vulnerable and completely primed for the health disaster that is about to unfold,” he told The Independent.

As the WHO began Covid-19 tests in rebel-held areas only at the end of last week, medics do not have a clear sense of the spread.

Refugees International told The Independent at least three people in Idlib have died showing symptoms of Covid-19, and several other patients had been quarantined.

Maram al-Sheikh, minister of health for the Syrian interim government anchored in northern Aleppo, said they have only one ventilator for every 26,500 people and “no capacity at all” to treat anyone with coronavirus.

“We have more than two million IDPs [internally displaced people] living in camps,” he told The Independent.

“We only have 65 hospitals, with just over 200 ICU beds and only 150 ventilators, for 4 million people.

“All hospitals are already full to capacity with patients.”

Inside Idlib: Syrians caught in the crossfire Show all 24 1 /24 Inside Idlib: Syrians caught in the crossfire Inside Idlib: Syrians caught in the crossfire Aftermath of an airstrike in a chicken farm in the town of Maarat Misrin, Idlib, Syria, March 2020. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Six displaced families were living in the farm, at least 16 people died in the late night attack. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Maarat Misrin attack in Idlib. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Maarat Misrin attack in Idlib. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Maarat Misrin attack in Idlib. (Photo: Yusuf Sayman) Yusuf Sayman Inside Idlib: Syrians caught in the crossfire IDPs are seen in a central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Hundreds of families live in the basement and car park of the stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire IDPs in central Idlib stadium. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire A scene from the Idlib market. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire A scene from the Idlib market. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire A scene from the Idlib market. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Suleyman Suleyman, a 24-year-old Arabic teacher, is seen in the al-Barayeem primary school, which was hit by an air strike on 25 February. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire The strike killed 3 adults, forcing the school to close. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Assadollah, a fighter just returned from the battle to recapture Saraqeb, poses for a photograph in the town of Binnish. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire A building hit by an airstrike few days ago in the town of Binnish. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Building in Binnish town. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Yousef Ramadan and his son are seen in the rubble of their apartment complex that was hit by an airstrike in the town of al-Fua, north of Idlib four days ago. (Photo: Yusuf Sayman) Inside Idlib: Syrians caught in the crossfire Nine were killed in the attack. (Photo: Yusuf Sayman)

He said the authorities have imposed some measures including restrictions on movement to neighbouring Turkey, where over 200 people have died from Covid-19 and more than 13,500 have been infected.

But Mr al-Sheikh said Syrian schools, universities and markets still needed to be sterilised.

“We badly need an awareness campaign. People do not realise what is coming to them,” he added.

In Idlib, a de facto governing body backed by the jihadist group Hayat Tahrir al-Sham has banned open markets and bazaars over coronavirus fears, but medics there say they still deeply concerned.

Dr Hassan Hamdy, an Idlib medic, said his hospital had no ICU beds free.

“All we have is oxygen tanks and painkillers, you can’t fight the disease with that, ” he said.

Northeast Syria: ‘If we have a small outbreak, we will run out of supplies immediately”

In the Kurdish held northeast of the country, health officials there said they have no Covid-19 tests and therefore no way of mapping the spread.

The only functioning testing machines were lost in October 2019, during Turkey’s cross-border incursion aimed at repelling the Kurdish-led Syrian Democratic Forces (SDF).

The SDF, together with the US-led coalition, declared a geographical victory over the so-called Islamic State last year. The SDF is holding at least 10,000 Isis fighters in overcrowded jails, as well as tens of thousands of Isis family members and supporters in camps, which again pose a major Covid-19 risk.

The Rojava Information Centre (RIC), a media organisation based in northeast Syria, told The Independent that Kurdish medics were relying on stop-gap solutions like repurposed malaria tests and temperature checks, to piece together an inaccurate picture of patients’ conditions.

Dwindling supplies have also hampered coronavirus response efforts: in January, under pressure from Russia, the UN Security Council closed the only UN aid crossing into north and east Syria.

Medics warn they now have only enough protective equipment for doctors to treat a maximum of 100 coronavirus patients.

“We can’t get supplies from anywhere and the WHO is not cooperating with us, the borders are shut,” said Raperin Hassan, a health official for the Kurdish-held region. “We have tried for over a month to get a supply of latex gloves from regime areas.”

A US armoured vehicle drives past a billboard for the Syrian Kurdish Women’s Protection Units (YPJ) (AFP/Getty) (AFP via Getty Images)

She added: “We have about enough gloves, masks and protective gowns for medics to look after about 100 patients with Covid-19. If we have a small outbreak, we will run out of supplies immediately.”

She said that they have 12 ventilators for millions of people.

The WHO could not be reached for comment by The Independent by the time of publication.

Dr Nima Saeed, the WHO’s representative for Syria, has previously said it was working on assigning a testing laboratory in northeast Syria.

Dr Saeed told the RIC in a recent interview that while closure of the sole crossing had complicated supply chains, they have not had any problems delivering supplies by liaising with Damascus.

There are also growing fears around the security of overcrowded prisons if there is an outbreak of coronavirus.

The largest camp, al-Hol, is home to more than 70,000 Isis supporters and family members who regularly stage protests, and there is no way to effectively isolate or quarantine anyone within the camp.

The country’s northeast is also under continued threat from Turkey. Although the fighting between Kurdish and Turkish forces has largely stopped, Human Rights Watch (HRW) said on Tuesday that Ankara had “weaponised” water during the pandemic, after seizing control of the Allouk water pumping station, which serves nearly half a million people in Hassakah.

The New-York based watchdog said that Turkish authorities had interrupted water pumping several times during the start of the year, impacting people’s ability to take basic precautions like hand washing – a vital preventative measure to stop the spread of coronavirus.

In regime-held areas of Deir Ezzor, there are unconfirmed reports about an outbreak of Covid-19 among forces from Iran, which is currently struggling to battle the worst outbreak in the region.

Mohammad Hassan, a Syrian journalist in the north, told The Independent he had unconfirmed reports of 60 cases with several members of Iran-affiliated forces in quarantine in Al Shifaa hospital along the Syrian-Iraqi border.

Activists on the ground said that with no official testing, the situation is impossible to gauge, but is critical because of the continued movement of pilgrims into the area from virus hotspots like Iraq and Iran.

“There is a Shia holy site in a town close to the border with Iraq, and many Syrians and Iranians are still visiting the place even during these days, potentially spreading the virus,” said Ahed, a local journalist, asking for only his first name to be used.

LIBYA: ‘We are a divided country at war, with effectively two health ministries’

The Libyan authorities are scrabbling to import medical supplies in the battle-ravaged Tripoli.

Fighting in the country still rages between the recognised Government of National Accord (GNA) alongside Turkey-back Syrian fighters, and forces belonging to Khalifa Haftar – a military commander who is loyal to a rival government in the east.

At least eight cases of the virus have been identified and no deaths, however, the government again lacks testing kits.

GNA officials told The Independent that their medical staff are not trained to deal with a pandemic and are already overwhelmed with battle injuries from daily shelling and airstrikes.

“The other problem is, we are divided countries, we effectively have two health ministries – the one in Tripoli and in the east,” said one GNA official, who asked not to be named.

“It will make it much harder to defeat the coronavirus if we cannot have a coordinated response, if we are still fighting against each other.”

The Libyan Red Crescent said they have donated all their protective equipment like latex gloves and masks to Tripoli’s hospitals in expectation of a rise in Covid-19 cases.

“We should be responding to battle injuries with protection, given anyone could be infected, but we have given most of our supplies away for the Covid-19 emergency,” said Red Crescent paramedic Asad Jafar.

Another major concern is a massive population of vulnerable migrants and refugees.

For years Libya has been one of the main gateways to Europe with, at its peak, as many as 180,000 migrants paying smugglers to cross the Mediterranean.

With a renewed crackdown on the smuggling trade within Libya, and restrictive measures in place in Italy, the flow has all but stopped – but the country still hosts a large migrant population.

Safa Msehli, a spokesperson for the International Organisation for Migration (IOM) said at least 1,500 migrants are being held in official detention centres, which are squalid and cramped.

“Our biggest concern is the unofficial detention centres run by militias and smugglers – we cannot reach those people,” she added.

YEMEN: ‘If we get a single case it will become an epidemic immediately’

Fighting in Yemen between Iran-backed rebels the Houthis and a Saudi Arabia-led coalition has flared since the weekend.

No coronavirus cases have yet been recorded because the country has been all but sealed off due to a Saudi-enforced land, air and sea blockade.

But doctors and medical charities told The Independent it is just a matter of time, with the country having no capacity to respond.

The five-year war has spawned the largest humanitarian crisis in terms of numbers.

An estimated 80 per cent of the population – or 24 million people – require some form of humanitarian assistance to survive. Two-thirds of the country are one step away from famine.

Adding to the woes is the worst outbreak of cholera in modern history, which has left the population incredibly vulnerable to a coronavirus outbreak.

Oxfam reported last week that there are 50 suspected cholera cases emerging every hour, compounded by the fact that around 17 million people – more than half the population – have no access to clean water.

In those conditions, coronavirus could rage through the country, where only half the medical facilities are still functioning.

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A recent report by the Yemen Data Project found that over the last five years, Saudi-led coalition aircraft have bombed medical facilities including hospitals and clinics 83 times, killing 95 civilians and injuring a further 116.

“The prospects are very bleak – Yemenis are far more vulnerable than any other population in the region,” said PHR’s Koteiche.

PHR together with the group Mwatana for Human Rights put out a report detailing the destruction to Yemen’s healthcare system.

Medics on the ground told The Independent they did not have the medical supplies to treat those with malnutrition, cholera or war wounds – let alone Covid-19.

“We have no additional equipment like protective gear, no available items like ventilators,” said Ashwaq Muharram, a doctor who has been fighting famine for the last few years in besieged Hodeidah.

“We have no place for isolation, quarantine. People can barely afford to eat as it stands. Whole swathes of areas do not have access to clean water.