Failing precautionary measures, unmet funding, and mistrust: What future lies ahead of COVID-19 vaccine in Syria?

Luay Ruhaibani| Saleh Malas| Habaa Shehadeh| Diana Rahima

Late 2020 official statements that final tests of the developed vaccines for the novel coronavirus (COVID-12) are showing positive results have inspired hope in the hearts of people that the source of fear and concern which destabilized nations and states across the world is soon to disappear. The case in Syria, however, was not the same, for people did not necessarily feel “relieved” by the news.

It has been nine months since the first COVID-19 positive case was announced in the Syrian regime’s control areas. Shortly after, more cases were declared in the areas run by the Autonomous Administration of North and East Syria, and then in the northwestern areas, where the Salvation Government and the Syrian Interim Government share dominion.

Even though the virus’ spread took an upward trajectory throughout Syria, the larger proportion of the population is still deprived of established preventative measures against its “lethal” effects.

Today, major states have various plans to obtain the vaccine and to manage the following process of distribution, undisturbed by the logistic, economic, political, or military challenges that stand behind the “poor” healthcare responses that Syrians are granted, which also threaten to present additional obstacles in the face of efforts aimed at obtaining the vaccine.

Based on interviews with doctors, government officials, concerned figures, and locals, this report investigates into Syria’s ability to handle the COVID-19 vaccine, given the mechanisms of action so far put in place by the three governments and the Autonomous Administration to address the outbreak. This extended report also demonstrates the impact of the economic turbulence and the healthcare system’s dire condition, as effected by the war, on the potential vaccination drive in Syria.

Syria’s logistics management put to test:

Would COVID-19 vaccine arrive in Syria?

Of all the said challenges, logistics pose the greatest obstacle to overcome, regardless of the different authorities that have marked control areas across the Syrian map. Nevertheless, the COVAX initiative is apparently unwilling to leave the matter to the care of these governing parties or their sense of commitment, after it put Syria on its list of 92 countries that are to get funded vaccines.

“Limited testing in all parts of the country makes the extent of the outbreak impossible to assess with any certainty,” Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, Mark Lowcock, said in his briefing to the Security Council on the humanitarian situation in Syria on 16 December 2020.

The statements made by the regime’s Ministry of Health that Syria will soon obtain the COVID-19 vaccine sparked a national and international debate, on whether Syria is prepared to receive, store, distribute, and embark on vaccination programs, considering the country’s current logistic, economic, and social conditions.

The government of the Syrian regime will receive a COVID-19 vaccine, which is scheduled to arrive in the country in the first quarter of 2021, Tawfiq Hasabah, director of the Emergency and Ambulance Corps under the regime’s Ministry of Health, stated on 22 December 2020.

“The vaccine brand is so far unidentified because it is the World Health Organization (WHO) that will recommend which vaccine category Syria should receive,” HashtagSyria, a local media outlet, reported quoting Hasabah.

Hasabah added that the vaccine will be purchased, but the Syrian government will make it available for citizens “free of charge.”

The WHO has promised to provide Syria with the vaccine in the first quarter of 2021, “but the organization has not yet confirmed the exact date of delivery,” Hasabah reiterated, stressing that further information on the type of the vaccine, or its price, remain unavailable.

COVAX explained

The COVAX pillar is founded by the WHO to provide lower-income countries with equitable access to the vaccine, including Syria.

The initiative brings together donor governments, which are already investing in the vaccine development; testing; and distribution processes.

 When approved, the initiative aims to make the vaccine available for countries that cannot afford its costs. 

The WHO added Syria to a group of 92 lower-income countries to be helped to obtain the vaccine as soon as it is approved.

Storage is the main challenge to vaccination efforts, given the persistent power cuts in Syria, a Homs-based otolaryngologist told Enab Baladi, requesting that his name be withheld for security reasons. “Vaccines must be stored according to a standard set of controls, which differs from type to type, or else vaccines turn ineffective.”

On ideal days, power would be available for four hours only, so it is necessary to provide vast generators and refrigerators. This, in turn, requires securing fuel that is a rare commodity, the otolaryngologist added.

In a joint report with UNOCHA, issued on 23 December 2020, the WHO stated that among its current key priorities is “engaging with the Ministry of Health on their vaccination strategy, including defining priority population groups.”

According to the report, laying the groundwork for delivery of the COVID-19 vaccine includes carrying out a downstream pipeline assessment to identify cold and supply chain requirements and gaps, including storage and warehouse capacity, as initial challenges identified are limited cold chain storage capacity below -25 degrees Celsius (C).

“Unfathomable” challenges in Northeastern Syria

In the northeastern parts of Syria, where the Autonomous Administration holds reins to power, vaccine-related negotiations are also underway, particularly since the region is allowed access to aid deliveries exclusively through the Syrian regime’s areas after the al-Ya’rubiyah Border Crossing with Iraq was shut down in early 2020.

“The Healthcare Authority is holding talks with the WHO regarding possible delivery of the COVID-19 vaccine to areas in north and east Syria,” the Autonomous Administration stated on its official Facebook page on 28 December 2020, quoting Dr. Joan Mustafa, the head of the authority.

It is still “uncertain” whether the vaccine will be distributed in north and east Syria or not, a Raqqa-based pulmonologist told Enab Baladi, requesting that his name be withheld for security reasons.

Other vaccines, including the polio vaccine, were often delivered to northeastern Syria through relief organizations that are associated with the government of the regime and under WHO-led programs, because the government “still maintains its prestigious position with international organizations, including the WHO,” the pulmonologist added.

The areas in northeastern Syria did not receive adequate healthcare assistance, which is the responsibility of the international community, he added.

The lack of medicines, the lack of ambulance services, and a shortage of health workers posed a barrier to accessing healthcare in all communities assessed by the REACH initiative, as listed by its report on the humanitarian situation in northeastern Syria of November 2020.

Northwestern Syria and challenges of recognition

In northwestern Syria, where the opposition is regnant, the healthcare sector is run by several healthcare directorates. These entities are either independent, such as the Idlib Healthcare Directorate, or affiliated to the health ministries of the Salvation and the Interim governments. However, they all have one common dilemma. They are local de facto administrative bodies—unrecognized by the international community legally or politically. Accordingly, their areas of action are not a priority in terms of COVID-19 vaccine assistance.

“A certain type of COVID-19 vaccine has not been chosen yet in northern Syria. And since there are many types, each having specific storage and transportation methods, we cannot exactly tell what challenges would arise,” dr. Rif’at Farhat told Enab Baladi, who is the Officer of the Vaccines Program in Idlib province.

There have not been any agreements with organizations or official entities to provide the area with the vaccine, he added. “Still, we have cold chains for the storage and transportation of conventional vaccines. The COVID-19 vaccine also will be handled as a conventional vaccine should a decision be made regarding the exact type to be delivered to the area.”

At the same time, the President of the Syrian National Coalition, Naser al-Hariri, on 24 December 2020, said that the coalition is seeking to obtain the COVID-19 vaccine. “The risks posed by the COVID-19 pandemic are high in the liberated Syrian territories, considering the acute shortage of personnel and the damage inflicted upon healthcare facilities in these areas by the regime and its allies.”

In northern rural Aleppo, the Free Aleppo Healthcare Directorate has not made any statements on the entities to assist the area in providing the vaccine, dr. Radwan Kurdi, the director of the Aleppo Directorate, told Enab Baladi.

The authorities running northwestern territories are not holding vaccine talks with the government of the Syrian regime, said dr. Muhammad Salem, a staffer of the Idlib-based Support and Coordination Office. GAVI-the Vaccine Alliance will provide Syria with vaccines sufficient to cover 20 percent of the population, planning to raise the supplies to answer the needs of 50 percent at a later phase. The alliance will target specific groups at each phase. These target groups are segmented based on the severity of their conditions, he added.

The United Nations Children’s Fund (UNICEF) and the WHO Technical Guidance will supervise the distribution process, dividing Syrian territories into three major areas—the northeastern region; the northwestern region; and the regime-held region, Salem added.

COVID-19 cases continue to rise in northwestern Syria. This rise is linked to higher testing capacities enabled by additional operationalized laboratories, quarantine centers, hospitals, and virus-treatment centers. Meanwhile, the Logistics Cluster is working with its partners to identify supply chain-related solutions in the event of a future roll-out of the COVID-19 vaccine, particularly cold chain transportation and warehousing capacity, according to the OCHA assessment report, issued on 21 December 2020.

Political and financial barriers: oppression, corruption, lack of resources

Nearly 10 years have passed since people first took to the streets to demand reforms in Syria, and peaceful demonstrations turned into a war that destroyed infrastructure and hampered service sectors and the economy. No area was spared this turmoil, which posed renewed barriers to humanitarian aid delivery and relief assistance efforts.

Drawing upon these poor conditions, the report of the UN Secretary-General, in a briefing to the Security Council on 11 December 2020, demonstrated that access to government-controlled areas, communities, and enclaves, including Eastern Ghouta and western Rif Dimashq, remains difficult owing to administrative and security approvals, for only 53 percent of assistance delivery permits were granted.

In southern Syria, insecurity and administrative restrictions continue to prevent aid delivery, even though the regime forces retook the area in July 2018.  In Rukban camp, for instance, the last aid supplies arrived in the area in September 2019.

Unlike the northeastern areas of al-Hasakah province and some parts of Raqqa province, UN deliveries to areas, such as Manbij and Ayn al-Arab/Kobanî, through Damascus are blocked due to rampant insecurity and the lack of an agreement between the de facto authorities there and the regime’s government.

The repercussions of the regime’s government’s policies were not limited to destroying hospitals and roads or the fatal threats of bombing and combat. In early October 2020, these policies disrupted the distribution of food aid to 220,000 people in areas outside the regime’s control in Raqqa, which were not resumed until 2 December 2020.

At the same time, violations of the ceasefire in northwestern Syria, along the buffer lines south of Idlib province and west of Aleppo province, have also temporarily hampered the delivery of humanitarian aid, owing to ensuing “security chaos.”

As part of its emergency response plans, the UN embarked on expanding the capacity of the roads to the Syria-Turkey joint border crossing of Bab al-Hawa, the single crossing through which 2020 humanitarian aid deliveries were authorized under Security Council Resolution no. 2533.  Road works of routes connecting the border with northern Aleppo continued uninterrupted until winter made carrying on with the reported expansions “impossible.”

Would authorities abuse COVID-19 vaccine?

Negotiations regarding COVID-19 vaccine delivery to Syria between the regime and the WHO have been ongoing for months, said dr. Atef al-Tawil, director of the Department of Communicable Diseases in the Ministry of Health.

Delay in vaccine delivery is “in the best interest of citizens,” since manufactures will be simultaneously working to increase production and decrease prices of the vaccine, and, consequently, make it available for larger numbers of countries, dr. al-Tawil added at the time. “It is pure business, the whole thing.”

The vaccine will be distributed “for free” to ministry-affiliated healthcare workers, and then persons with chronic disses, such as heart, diabetes, kidney, and cancer patients, he stated in an interview with the pro-regime Sham FM radio station.

It is true that COVAX initiative is a major sponsor of the vaccine delivery to Syria but providing the most vulnerable groups with the vaccine over the first half of 2021 requires additional investment and financing.

The measures and the “citizen’s interest,” which are the most recurrent topics of statements by Syrian regime officials failed to materialize in the battle against the virus. These measures were not applied on the ground on the pretexts of healthcare and service sector deterioration, and destruction caused by “terrorism.”

Also, in former reports, Enab Baladi covered the government’s failure at implementing precautionary measures, announced by officials in Homs, Daraa, Aleppo, and As-Suwayda. In these areas, the residents considered the fight against the virus and flattening the curve their own responsibility, but their efforts were met by lawsuits and arrests.

It is logistics, not economy, that poses the greatest challenge, Khaled Tarkawi, an economist at Jusoor for Studies Center, told Enab Baladi. He said that the various ruling authorities in Syria are unlikely to exploit the vaccine for revenues, adding that vaccines could be abused for illicit gains, “but not at the early stages of the delivery process.”

Tarkawi gave the following example, “at earlier stages, upon receiving a part of vaccine doses, allocated by Russia and China, the regime will use this in the media, with a nuance that the vaccine was distributed for free. Later, however, the regime might start selling the vaccine.”

Brokering cause vaccine prices to skyrocket

Economist Tarkawi added that the regime would probably delay obtaining the vaccine, to July 2021 at the earliest, because the regime expects that other ruling parties in Syria will be donated the vaccine, instead of buying it.  “Furthermore, the regime is nowhere near obtaining Russian or Chinese vaccines, which are in high demand.”

The reason why Syria depends on donated vaccines is the international dynamics that govern the vaccine trading because vaccines’ buying and selling operations are conducted under larger brokering deals, Tarkawi said.

To put this in perspective, it would be difficult to purchase a million vials of Pfizer, each costing $25, for $250 million, because brokers will definitely attempt to achieve higher revenues. Syria cannot be part of such bids.

It is too early to speak of Syria’s number on the recipients’ list, dr. Mazen Kwara, Regional Director of SAMS in Turkey and Northern Syria, told Enab Baladi, adding that Syria would be among the last countries to receive the vaccine.

The competition between great and wealthiest countries in obtaining the vaccine, and, in return, the poverty and reliance on donations in developing countries, are of the key factors that may hamper any early vaccine delivery to Syria, he said.

He added that one other challenge to vaccine distribution in Syria is funding, stressing that late vaccination would have a negative impact in a country where healthcare services are nearly nonexistent while the pandemic continues to spread.

COVID-19 vaccines: types and efficacy

Usually, it takes vaccines several years, or months, to be approved, but this is not the case with COVID-19 vaccines, which are granted specialized emergency use authorizations despite the little data collected by developers.

Pfizer/Biontech

Developed by the U.S. and Germany, Pfizer/Biontech is a two-dose vaccine, separated by 21 days. The vaccine efficacy reaches 95 percent, seven days after the second dose. Pfizer and BioNTech’s vaccine maintain efficacy for several weeks when kept at -70 degrees C, and for five days when stored at 2+ to 8+ C—namely standard refrigerator temperature.

Moderna

Developed by the U.S., Moderna is a two-dose vaccine, separated by 28 days. The vaccine efficacy is estimated at 94.1 percent. Moderna vaccine maintains efficacy up to six months when kept at -20 degrees C and preserves a stable efficacy for 30 days when stored at standard refrigerator temperature.

Sputnik V

Developed by Russia, the vaccine is named after the first Soviet space satellite Sputnik, while the V stands for victory against COVID-19.

Sputnik V is a two-dose vaccine and proved effective in 91.4 percent of cases. The lyophilized (dry) form of the vaccine can be stored at a temperature of +2 to +8 degrees C.

Sinopharm

Developed by China, Sinopharm is a two-dose vaccine, taken over the course of 28 days. Since the first dose’s efficacy is only 97 percent, the manufacturers advise people to take a second dose to reach 100 percent efficacy. However, clinical trials demonstrate that the vaccine can only reach 86 percent efficacy.

Unlike U.S. developed vaccines, Sinopharm must be stored at standard refrigerator temperature, maintaining the advantages of conventional vaccines. This makes it easier to transport and distribute.  

Oxford-AstraZeneca vaccine

Developed by the UK, AstraZeneca is a two-dose vaccine. When volunteers were given two full doses, the vaccine’s efficacy reached 62 percent, but when given half a dose, followed by a full dose, efficacy increased to 90 percent. It is still unclear why different dosing regimens resulted in different efficacy rates.  

Unlike Pfizer’s jab, the Oxford vaccine can be stored in a normal fridge. This makes it much easier to store and distribute to various countries around the world.

Russian vaccine: source of regime’s hope, and citizens’ nightmares

There has been little official information on the communication between the regime’s Ministry of Health and COVID-19 vaccine manufacturers. Nevertheless, in media statements, the regime was rather open about its intentions to obtain the vaccine produced by its Russian alley.

In a Sputnik interview, on 7 October 2020, the head of the Syrian regime, Bashar al-Assad, said that Syria will import Russia developed COVID-19 vaccine as soon as it is available on the global markets.

The vaccine’s arrival in Syria is subject to communication with the Russian authorities, once it is available globally, al-Assad said, describing the matter as “important” and indicating that the required quantity is contingent on the amounts manufactured in the first place. Needed quantities are also a matter to be decided by  Syrian health authorities.

For his part, the regime’s Minister of Foreign Affairs, Faisal Mekdad, has officially discussed vaccine delivery to Syria in a meeting with Ted Chaiban, UNICEF Regional Director for the Middle East and North Africa, reported the local al-Watan newspaper.

Syrians will not trust the Russian vaccine unless it is delivered through the WHO, the Homs-based otolaryngologist told Enab Baladi.

The people’s concerns over the vaccine and its harmful side effects are not objective, especially since the “honor code” of the doctors’ committee, assigned making decisions about the type of vaccine to use and distribute in Syria, would prevent them from putting people’s lives at stake, the otolaryngologist added. “The vaccine will ultimately reach [these doctors’] homes, their families, and relatives too. So, doctors cannot greenlight a harmful vaccine,” he added.

Officials, however, will delay obtaining the vaccine unless it has been produced by international companies, “European or American,” he said.

Asking that his last name be withheld for security reasons, Muhammad, a young man based in rural Homs, said that receiving the Russian jab would make him feel like “a lab mouse.”

Russia has used Syria as “a ground for weapon trials and training pilots,” he added, stressing that it is necessary to get vaccinated, should vaccines prove effective, particularly to protect his family.

The upheavals that Syria witnessed, including displacement and insecurity, amount to a “thousand COVID-19 pandemics,” Khalid said, 37 years old young man based in southern rural Damascus. He was arrested and dismissed from his job for participating in the 2011 protests.

“I will not receive any COVID-19 vaccines,” he told Enab Baladi.

Conspiracy theory in Northern Syria

In northeastern Syria, the population is suspicious about the vaccine too, Muhammad al-Badran, 35 years old, told Enab Baladi.

The measures imposed by the Autonomous Administration were insufficient to combat the virus, not to mention the people’s lack of commitment to these measures, he added. “I will not take the vaccine, nor my family. I cannot trust the vaccine because many people still believe the whole virus thing is a lie. The cases probably had some sort of severe flue or pneumonitis.”

There have not been enough data, or studies, on the COVID-19 vaccine across the world, not to mention anti-vaccine rumors and conspiracy theories regarding the pandemic and its spread, dr. Rif’at Farhat noted, Officer of the Vaccines Program in Idlib province. “These [ideas] will certainly instill fear among the people and drive a portion of the population to refuse to take any of the vaccines.”

The COVID-19 outbreaks in the area were less severe than expected. Even though he was initially afraid that he might contract the virus; he will not receive the vaccine, Idlib-based Fateh Rislan, 25 years old media activist, told Enab Baladi. “I am still unsure whether the COVID-19 thing is a game, or not!”

However, older people should be prioritized when the vaccine becomes available, he added.

Poll: Vaccine worries overwhelming majority

In an online poll, Enab Baladi found that the majority of the participants are reluctant to receive COVID-19 vaccine jabs. Out of 191 participants, 72% said that the vaccine is a source of anxiety even though the pandemic is still taking an upward trajectory. The remaining 28%, meanwhile, said they will receive the vaccine when it becomes available in Syria.