How do you do social distancing in a refugee camp?

Syrians now entering their 10th year of war could be forgiven for believing they have already faced the modern equivalent of the biblical Four Horsemen of the Apocalypse.

But the millions of refugees and internally displaced Syrians are bracing for yet another trial: the coronavirus.

Even technologically advanced nations like China, Italy, and the United States are struggling to stop the spread of COVID-19. But the rudimentary camps full of Syrian victims of conflict – many of them having endured a cold winter in tents, lack of basic hygiene, and malnourishment – may be uniquely vulnerable to the global pandemic.

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Experts say there is still a window to act to take life-saving health and hygiene measures. And one key is for Western donors to recognize that preventing an uncontrolled regional outbreak improves their own long-term risk calculations at home.

That will be a challenge, as countries around the world remain engulfed by their own domestic needs.

And even before the coronavirus, humanitarian efforts in the Middle East were beset by years of conflict; donor fatigue; neglect as populations filled sprawling camps or moved, newly homeless, toward safer borders; and weak governments besieged by popular protests in Iraq, Lebanon, and Syria.

The trajectory of the virus suggests that it will hit areas with high concentrations of refugees – such as Syria, Afghanistan, Yemen, and Venezuela, says Jan Egeland, head of the Norwegian Refugee Council (NRC). “Then my open question to any decision-maker ... trying to curb the spread of the virus: How can you do social distancing, if you live in a refugee camp with 10 people per small tent?”

“How can you do constant hand-washing, if your water ration is three liters per day, and that’s supposed to go to drinking and cooking? And how,” he continues, “are you supposed to care for the infected and quarantine the vulnerable, when there is no health care?”

Grim conditions in opposition-controlled Idlib, Syria, highlight the depths of the challenges ahead. Recent bombardment of this last, shrinking rebel enclave has forced one million people from their homes. Syrian government forces backed by Russia and Iran have captured nearly half of the enclave since renewing an offensive last December with relentless bombing.

That forced into even tighter quarters the 3 million people in Idlib – among them Islamist militants, including former Al Qaeda affiliates, trucked there as part of cease-fire deals brokered when other rebel-held regions were defeated.

The latest United Nations situation report for northwest Syria, published Monday, notes: “Inadequate land for the formation of new camps and sites leave many new IDPs [internally displaced people] in overcrowded conditions without formalized camp support.”

It adds that, “access to food has become an increasing concern.” Indeed, some 1.5 million people in Idlib depend on food aid, and in January alone, 1,227 trucks crossed the border with supplies from Turkey, the largest number in seven years.

Felipe Dana/AP

A boy walks out of a heavily damaged building where he is currently living, in Idlib, Syria, March 12, 2020. Idlib is the last urban area still under opposition control in Syria, located in a shrinking rebel enclave in the northwestern province of the same name. Syria’s civil war, which entered its 10th year March 15, 2020, has shrunk in geographical scope – focusing on this corner of the country – but the misery wreaked by the conflict has not diminished.

A tenuous cease-fire brokered March 5 by Turkey and Russia, both of which have troops deployed in and around the province, still holds. But the U.N. notes that even before the December offensive began, the population of Idlib was “already extremely vulnerable.”

The World Health Organization says Syria’s health system – especially after years in which government and allied forces targeted health infrastructure behind rebel lines – is “on its knees.” Beyond Syria’s borders, neighbors Turkey, Lebanon, and Jordan have absorbed millions of refugees.

“In Syria you have this perfect storm. When we needed the health system the most, it was bombed. When people were supposed to be able to quarantine and distance themselves, they had to flee their houses to temporary, crowded camps,” says Mr. Egeland.

“So as bad as it is in Italy and China and increasingly in the rest of Europe, I cannot see why it would not be 10 times worse when you have none of the mitigating measures that we have,” he says.

But the solution that can ease the impact is still within reach, if donors can see the need for a holistic approach.

“What can we do? Water and sanitation. It’s not rocket science. It’s a logistical challenge,” says Mr. Egeland, whose 14,000 field workers with NRC aim to double to 4 million the number of people across multiple war zones they reach with water and sanitation.

That means more latrines, and 10 times more running water points for washing, and decongesting camps by tripling or quadrupling the space devoted to displaced people. It means expanding health care, public hygiene campaigns, and building quarantine facilities – all actions the NRC says may keep the virus at bay in the Middle East, and so make it less likely to persist there as a threat to the rest of the world.

The need to act is urgent, experts say.

“You have 6 million refugees from Syria, 6 million internally displaced in Syria – including a million recently in Idlib – another 1.5 million displaced in Iraq, all of them living in oppressively unsustainable conditions that, by all indications,” are consistent with transmission of the virus, says Julien Barnes-Dacey, head of the Middle East and North Africa program at the European Council on Foreign Relations in Brussels.

Another key factor is the governments of Syria, Lebanon, and Iraq, all “hollowed out” over recent years by multiple layers of crises and short on leadership and resources, says Mr. Barnes-Dacey.

But that very concern may be causing some shift in regional thinking, with Exhibit A being unexpected support for Iran – epicenter of the virus in the Middle East – by the United Arab Emirates and some other Persian Gulf states, despite long-simmering tensions with Iran.

The Islamic Republic is host to 9 out of 10 of the 21,000-plus confirmed cases of COVID-19 across the Middle East, and a number of its leadership elite are among more than 1,800 citizens who have died. Suffocating U.S. sanctions have complicated both medical exports to Iran and the cash transfers to pay for them.

The UAE nevertheless expressed its support for Iran and “highlighted the importance of collective work and efforts to survive this global challenge.” It made two shipments of medical supplies to Iran, including two planeloads carrying thousands of pairs of gloves, masks, and other equipment, on March 16.

“They recognize obviously that what happens in Iran doesn’t stay in Iran, and it can easily overflow across the Gulf,” says Mr. Barnes-Dacey.

Such moves are “first and foremost about self-preservation, and [Persian Gulf states’] desire to ensure that the situation in Iran is containable,” he says.

“But it points to a model of possible regional collaboration that could be a constructive way of reinforcing efforts to contain and manage the situation,” says Mr. Barnes-Dacey. “If Arab Gulf states are prepared to do something with Iran, it suggests that fault lines and conflict lines will likely be deprioritized in the case of a threat that challenges everyone equally.”

On a wider scale, that is the case the NRC’s Mr. Egeland is making to donor countries like the U.S. and members of the European Union, about the need to look now at easing the effect of the virus among the most vulnerable refugees and displaced in Syria and beyond.

“Why make strongholds for the virus, anywhere in the world, when we live in a global world with global pandemics?” he says. “If it gets a stronghold in camps with half a million people ... it means it can always come back.

“If hand-washing is a mitigating factor in New York City, it’s also important for New York City that there are hand-washing facilities in Syria, because it started with patient zero in Wuhan, and now we are sitting in quarantine in Oslo,” says Mr. Egeland, who is under mandatory quarantine there after a visit to South America.

“So if there are no hand-washing facilities in Syria a year from now, how can you get rid of this virus? It’s a perfect example of ideals and interests intertwined.”

[Editor’s note: As a public service, all our coronavirus coverage is free. No paywall.]