In war-torn Syria, contact tracers are fighting against the odds
In the last parts of Syria still under rebel control, a grassroots network of coronavirus contact tracers have to battle suspicion and fear to keep the pandemic at bay
by Betsy Joles
By the time Shaker Alhamedo learned his colleague had Covid-19, the doctor had already travelled to a hospital in another province, meeting his parents along the way.
Alhamedo returned to Bab al-Hawa hospital in northern Syria near the Turkish border to quarantine with three others who had worked closely with the infected doctor. Days later, he developed a fever. He knew he had Covid-19 when he couldn’t taste his drink. Then, he started having trouble breathing. When his test for Covid-19 came back positive, Alhamedo felt a wave of dread. With the diagnosis came the reality that northwest Syria was a pandemic zone, and that doctors – usually seen as war-time heroes – would be blamed for bringing the disease inside.
It had taken six months for coronavirus to find its way to northwest Syria, an area hard hit by the country’s nearly decade-long war. The region of around 4.1 million encompasses Idlib, the last rebel-held enclave in the country, where a government offensive backed by Russia earlier this year displaced around one million people, some of whom were already uprooted from other parts of the country. Years of destruction there have left swathes of the population impoverished and living precariously in overcrowded camps and informal settlements, making the region particularly vulnerable to the spread of disease.
Healthcare facilities in northwest Syria damaged by years of targeted attacks were already crippled before Covid-19 went global, and many lacked basic equipment like ventilators and personal protective equipment needed to treat coronavirus patients. As infections in neighbouring Turkey rose, the government there closed its borders, and supply channels to the already isolated region became even more limited. When Syrian officials announced the first case of Covid-19 in a government-controlled area in March, the northwest seemed primed for disaster.
Doctors and aid workers in northwest Syria sounded the alarm early as the coronavirus spread like wildfire around the world. But for months, the region was spared, providing a cushion for a Covid-19 task force composed of local and international NGOs, and an army of contact tracers to prepare for the worst. In parallel with doctors treating coronavirus patients, these contact tracers – usually working as social workers and community health workers – have undertaken the herculean effort of trying to keep clusters of infections at bay.
Contact tracing is a big task anywhere. It requires a contact tracer to dig into another stranger’s personal information to find out where they’ve been, if they’ve experienced symptoms, and if they’re telling the truth about any of it. Health experts have praised contact tracing as a crucial tool in fighting the spread of diseases and say it could spare communities from having to go under full lockdown.
But northwestern Syria didn’t have the option to implement a centralised, co-ordinated contact tracing scheme. There, several military groups and de-facto authorities claim control. Decision-making is often localised and actions carried out by volunteers and groups like Syria Civil Defense, also known as the White Helmets, who are more used to helping people cope with the physical devastation of war.
The decentralised context in northwest Syria means contact tracing is done from the bottom-up; hundreds of local aid workers rely mostly on applications like WhatsApp and familiarity with communities where they are usually providing war-relief. The grassroots strategy to get ahead of new infections is an unlikely Covid-19 success story about how communities can mobilise when they have no other choice.
At the heart of the effort is an army of foot soldiers who are locating potential sources of infection at their own risk. Finding contacts sometimes involves physically going to their communities to search for them. “Sometimes we don’t know exactly where [a contact] is,” says Mohamad Khayrat, a supervisor and trainer at Relief Experts Association, an organisation involved in contact tracing in the region. Once contact tracers locate and identify contacts, he says, they check in with them through WhatsApp daily to find out if they have any symptoms.
Contacts often don’t know they’ve met with someone who is now infected, so contact tracers have to explain to them what happened. From there, Khayrat says contact tracers assess their level of risk of using a ten-point scale: three points each for fever and dry cough and two points each for fatigue, and loss of taste or smell. If someone has six points or above, they are tested. In the past for a person to get tested, they had to have previous contact with an infected individual or cluster of infections. But since cases have spread beyond those clusters, this condition no longer applies.
Contact tracing in a war zone is far from seamless. Distrust of governments has spawned an atmosphere of suspicion among communities who have lived through years of conflict. In addition to avoiding sharing contacts, sometimes people give false information or aliases when asked by contact tracers. “These names spread for security issues, so some people are known for these names only,” Khayrat says. This happens less than it used to, he says, but it can still be hard to get people to take quarantine seriously when they are used to warding off more visceral threats.
The number of confirmed cases in government-controlled Syria currently stands at 2,830. By comparison, the number of confirmed cases of coronavirus in northwest Syria is only at 93. While the infection count remains low, the number of contacts currently under observation – 780 – suggests that if a tight lid isn’t kept on infections, things could quickly spiral out of control.
Contacts spread far and widely early on, with doctors moving between cities and across borders for their work. The first Covid-19 patient from Bab al-Hawa had a total of 247 contacts, among them doctors and patients at the hospital where he was working, who were told to quarantine. After he tested positive for the virus, Alhamedo also faced the task of recounting everyone he had seen during his travels and contacting them to see if they had symptoms, too, in case he’d already been infected at that time.
Yaser Alfrouh, a coordinator for the Early Warning Alert and Response Network (EWARN), a disease surveillance system, says 600 more contact tracers have received training and are on standby in case things get worse. EWARN has recently started to use an outbreak investigation tool called Go.Data to help with data collection but success with the app is touch and go. Alfrouh says if a contact tracer’s phone is old or slow, for example, sometimes the application crashes unexpectedly. For now, for data collection to work, there still needs to be people scattered around the region to help with the information gathering process.
The spread of the virus among itinerant and internally displaced populations in the region poses an added challenge for contact tracers. Alfrouh says EWARN is trying to set up centralised quarantine centres for internally displaced people who may not have a home to isolate in. But in some cases, by the time contacts are identified, they may have already moved to another province or gone back home. In other cases, displaced people may be bringing the infection back with them.
In late July, the quasi-government in Sarmin, a town in the eastern countryside of Idlib province, quarantined the whole town after a woman returning from a government-controlled area tested positive for the virus. Abdulhay Tannari, a physician and medical director of a hospital in Sarmin, says after the woman came to his hospital with Covid-19 symptoms, they started trying to compile a list of people to test and quarantine. “We are living in a small town, and here in urban areas, all the people know each other,” Tannari says. “They made contact with a huge number of people.”
Tannari says contact tracers helped find 14 people who’d traveled with the infected patient, their family members, and others who’d been in contact with them daily, to test them. But since they couldn’t test all potential cases, Tannari says health authorities decided to isolate the whole town instead. So far, just as the lag in coronavirus entering northwest Syria surprised people on the ground, the slow spread among populations that seemed fated for disaster is confounding. “What’s happening? Why are they not infecting them? We don’t know,” Tannari says.
Contact tracers, much like doctors in northwest Syria, have grown accustomed to these kinds of puzzles working in areas long plagued by insecurity. When it comes to controlling the spread of an invisible threat, for now, the best solution remains a low-tech one: having bodies on the ground in communities where the disease may be silently spreading.
And for contact tracing to work, like anything in this part of Syria, there has to be a certain level of trust – something Alhamedo felt falter for the first time as a doctor. Before the Covid-19 outbreak, Alhamedo was often working as a surgeon on the front lines of hospitals under fire or in areas hit by airstrikes. During those days, health workers were seen as guardians in places where people felt neglected and forgotten.
Alhamedo was the last in his group of four quarantined at Bab al-Hawa to recover, spending a total of 17 days in the hospital. He spent the final three days in isolation after his colleagues were released – some of his hardest days as a doctor and a time when even the risk of war seemed less daunting than the feeling that he might be a threat to people he vowed to protect. “These moments under bombing were very difficult, physically and sometimes psychologically,” he says. “But they were not like the moments when I [had] the coronavirus.”
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