It is urgent for Syrians to put an action plan against Covid-19 on the table
CEO of Smart News Agency
Former scientist in Molecular Biology at the CNRS in France
This analysis does not reflect official views, but is intended to open debate over health policy in rural Syria to fight against the coronavirus epidemic.
Specialists can send their own views and replies to this article here.
The now well-known paradigm to control the epidemic of Covid-19 has been exposed widely by health authorities all over the world. Although complex to achieve, it can be summarized by a simple measure: flattening the curve of infected cases per day over time in order to prevent saturating the health system capacity. It relies on the combination of raising the capacity of the health system to treat critical cases, especially those needing intensive care, and delaying the spread of the disease through social distancing, hygiene measures, eventually distribution of personal protective equipment (PPE).
South Korea and other Asian countries have more or less succeeded in achieving this goal, and their way to deal with the epidemic has emerged as a model to emulate. This is certainly a lesson for many countries - those who can adopt such measures - to slow down the spread of the disease to reach the grail: always having a number of critical patients lower than the capacity level of the health care system.
Nevertheless, the means to reach this goal has proven very difficult in other contexts, such as in Italy, Spain and even the US, although unprecedented measures have been taken by these countries. In war-torn countries, even the most optimistic can’t even imagine applying such measures due to the total lack of infrastructures, equipment and because of the socio-economic context.
However, there is some hope for countries such as Syria, and perhaps to regions in the Arab world lacking the capacity that need to be deployed to imitate what the developed countries are struggling to achieve. Particularly, potential solutions that could work in Northern Syria may also work in the Palestinian occupied territories and in the Gaza strip.
In Syria, for example, one may not consider delaying the spread of the virus through social distancing, hygiene measures and systematic use of PPE, where millions do not have daily access to water and soap. Certainly, millions will be infected, and rapidly due to the high density of population, many of them residing in makeshift camps.
In such a context, the paradigm of the curve flattening must be revisited. Instead of aiming at reducing the number of new cases per day in the general population, one should aim at reducing the number of critical cases only. Here is why.
The demographic context in Syria is favorable as compared to developed countries.
In Syria, the population pyramid is such that the 0-9 year’s old group represents 21% of the total population. According to the current statistics on Covid-19 pandemic, this group of age do not present risk of mortality (death rate = 0).
World statistics on Covid-19 show that death rate for the age group of 10-49 year’s old is 0.2% to 0.4%. This group representing people with low risk of mortality represents 64.5% of the total population of Syrians.
The elderly group, the most vulnerable to the disease, composed of people 60+ year’s old, represents only 7.3% nationally in Syria. Death rate in this group is comprised between 3.6% and 14.8%, depending on the age.
Interestingly, the UN statistics on Syrian refugees updated in March 12th, 2020 shows that the 60+ group of age represent only 0.8% of male and 1.3% of female for refugees living in camps. The demographic figures for IDPs are uncertain, and we will postulate that they compose 1 to 10% of the population in camps.
Focusing on the situation in Northern Syria, the population reaches 4.2 million people. Thus, the number of people extremely vulnerable to the disease should be comprised somewhere between 40.000 and 400.000, when we take into account the age parameter only.
Another data, more encouraging, is the gender parameter. Globally, the mortality rate is about 40% lower for women as compared to men, whether calculated on confirmed cases of infection or on all cases of infection. As women tend to be more represented in the aged groups in Syria, the expected mortality rate should thus be globally lower.
All together, these data suggest that in Syria, and probably in other countries with similar demographic figures, a sound and pragmatic way to deal with the epidemic should rely not only in increasing the number of ICU beds and health system capacity in general, but most importantly at reducing the risk of infection of the vulnerable population.
Such a strategy might not be applicable in Japan for example, where the elderly represent a very large fraction of the population. To the contrary, in Syria, one fifth of the population is de facto not exposed to Covid-19 mortality (0-9 age population), and only a relatively small portion is highly vulnerable, the elderly. Indeed, not only the elderly people are poorly represented in the population pyramid, but it is the same group that is mainly affected by health pre-conditions enhancing the mortality rate of Covid-19: hypertension, cardiovascular diseases and diabetes.
In North Syria, only about 200 ICU (Intensive Care Unit) beds are available with only 95 ventilators for adults in surgical and internal diseased hospitals .
Although necessary, enhancing the ICU capacity to the needed numbers is hardly feasible in a short period of time in Syria due to the war context, the shortage of international help, and the reduction of cross-border activities. In developed countries, the number of ICU beds is comprised somewhere between 10 and 35 per 100,000 capita. Which means, if we applied the same quota in North Syria, 400 to 1400 beds would be needed. North Syria does not even have enough medical and paramedical staff to deal with these numbers. Thus, focusing only on raising the health system capacity cannot be the clue to the solution.
A complementary measure, consisting in reducing and delaying the number of critical cases arising over time can be achieved by two means. First one involves slowing the spread of the disease among the population. This is hardly possible in North Syria, where most of the people live in harsh conditions in camps or in rural areas. The second one involves preventing the vulnerable people - the ones that have the highest chance of developing severe or critical symptoms when infected and thus requiring ICU beds – to be infected by the virus.
The latest might be the clue solution that could be applied rapidly in Northern Syria. It will require hard work, political will and organization, but it is feasible. It will consist in protecting from infection the elderly and the people presenting health pre-condition unfavorable to Covid-19. For that, one could imagine creating dedicated shelters, nursing homes and clean hospices to host them and by applying adequate processes for taking care of them without importing the virus within these protected communities.
All concerned parties should unite their capacities towards this strategy through a Syrian-led task force comprising: WHO, international donors, international NGOs, interim government, local authorities, health and relief workers, media, and most importantly, the local civil society and local communities themselves.
The international community will need to provide the necessary support, not only as a gesture of solidarity, but also as a way to prevent the generation of a reservoir of a human coronavirus, potentially prone to evolve and generate new strains if not eradicated rapidly worldwide.