Coronavirus cases are surging to the worst levels of the pandemic in a rebel stronghold in Syria, a particularly devastating development in a region where dozens of hospitals have been bombed and that doctors and nurses have fled in droves during 10 years of war.

The total number of cases seen in Idlib province, an overcrowded enclave with a population of four million, many of them internally displaced, has more than doubled since the beginning of August to more than 61,000.

In recent weeks, daily new infections have repeatedly shot past 1,500, and authorities reported 34 deaths on Sunday alone, figures that are still believed to be undercounted because many infected people do not tell the authorities they are sick.

The situation has become so dire in the northwestern province that rescue workers known as the White Helmets who became famous for digging through the rubble of bombings to find victims now mostly ferry coronavirus patients to the hospital or the dead to burials.

“What is happening is a medical catastrophe,” the Idlib Doctors Syndicate said this week as it issued a plea for support from international aid groups.

Idlib faces all the challenges that countries around the world went through during the pandemic: Its intensive care units are largely full, there are severe shortages of oxygen and tests, and the vaccination programme has been slow to take off.

But extreme poverty and the ravages of civil war have made the situation in Idlib uniquely terrible. Half of its hospitals and health centres have been damaged by bombing, and the health system was close to collapse even before the pandemic.

A large number of medical personnel have fled the country seeking safety and opportunities abroad. Tens of thousands of its residents live in crowded tent settlements, where social distancing and even regular hand-washing are all but impossible. And increasing violence in the region is now threatening to make matters worse.

Large parts of Idlib and the neighbouring Aleppo province remain in the hands of Syria’s armed opposition, dominated by groups including al-Qaeda-affiliated fighters who have struggled to respond to the outbreak.

The infections intensified in August, apparently driven by the more contagious Delta variant and gatherings for the Muslim feast of Eid al-Adha.

Cases and deaths have also been increasing in recent weeks in government-held areas and those under the control of US-backed Kurdish-led fighters in the east, but the situation appears to be worse in Idlib, though it is hard to get accurate figures of COVID-19 numbers throughout the country.

In response, the political arm of the armed group that runs Idlib has closed some markets, forced restaurants to serve meals only outdoors, and delayed the opening of schools by a week.

But most residents are daily labourers who could not survive if they stopped working, making full lockdowns impossible.

“If they don’t work, they cannot eat,” said Idlib resident Ahmad Said, who added that most people cannot even afford to buy masks.

What is more, a population that has suffered through so much already is often too weary to follow restrictions that have tested people even in easier circumstances.

“It is as if people have gotten used to death,” said Salwa Abdul-Rahman, an opposition activist who reports on events in Idlib. “Those who were not killed by regime and Russian airstrikes are being killed now by coronavirus.”

The vaccination campaign meanwhile, has been slow, although the arrival of some 350,000 doses of a Chinese vaccine earlier this month could help. According to the World Health Organization, only about 2.5 percent of Idlib’s population has received at least one shot.

The new virus outbreak also comes amid the most serious increase in violence in Idlib, 18 months after a truce reached between Turkey and Russia who support rival sides in Syria’s conflict brought relative calm. In recent weeks, air attacks and artillery shelling by government forces have left dozens of people dead or wounded.

At al-Ziraa hospital, Dr Muhammad Abdullah says there is no sign that the outbreak has reached its peak yet.

But for some Idlib residents, getting infected is the least of their worries.

“We have gone through more difficult situations than coronavirus,” said resident Ali Dalati, walking through a market without wearing a mask. “We are not afraid of coronavirus.”