‘This is war’

In Dagestan, Russia, where a 500-person wedding is considered modest, can a strong collective mindset stop COVID-19?

In the Republic of Dagestan, a federal subject on the southern edge of Russia that stretches from the Caspian Sea into the Northern Caucasus Mountains, weddings and funerals mean enormous crowds. Hundreds and even thousands of people regularly gather to celebrate major life events not only from all over the republic but from all over Russia as well. Those traditions don’t fit well with the circumstances of a global pandemic. However, the strong communities that underlie them have been helping Dagestan pull off miracles of self-organization and mutual aid, especially when there’s no hope of receiving government support. Meduza asked journalists Patimat Amirbekova and Vladimir Sevrinovsky to take a deep dive into Dagestan’s anti-coronavirus efforts from the seaside capital of Makhachkala to the republic’s remote mountain villages.

According to the Dagestani branch of Rospotrebnadzor, Russia’s federal public health agency, the republic had 3,192 recorded cases of COVID-19 as of May 15, 2020. Twenty-seven of those infected individuals have died. On a national scale, that puts Dagestan in fifth place for the total number of cases confirmed in a single region. Still, many Dagestanis think those numbers are artificially low. A list of doctors thought to have died of COVID-19 has been circulating on social media, growing to more than 25 names last week. Abdurashid Magomedov, the republic’s Internal Affairs Minister, posted a video message on Instagram saying that three of the police officials serving underneath him died of pneumonia in the final week of April.

Across Russia, as of May 15, more than 6.4 million coronavirus tests had been conducted, yielding an average of about 4.4 tests per 100 people. Only 31,635 of those tests have gone to Dagestan, making for a per-capita testing rate about four times lower than the national average. Regional Health Ministry officials also told Meduza that only one person known to have died from COVID-19 in Dagestan received an autopsy.

Meanwhile, the Caucasian republic’s healthcare system is in crisis. Meduza’s sources said that space is running out in both urban and rural hospitals, and ambulances in the regional capital of Makhachkala come very late or not at all as they grapple with near-impossible workloads. One Makhachkala resident said in an interview that when he called an ambulance in recent weeks, he was told it would arrive within 24 hours. Operators told another resident of Dagestan’s capital that about 400 people who had called for an ambulance before her were still waiting in line.

At the same time, the coronavirus pandemic has mobilized civil society in Dagestan on a massive scale: people across the republic have organized to help the virus’s victims without guidance from the regional government and sometimes even against the government’s wishes.

A chlorhexidine wedding

Dagestan’s first confirmed case of COVID-19 was officially recorded on March 27. That same day, at a banquet hall called “Gretzia” (Greece) in the city of Kaspiisk, a wedding was in full swing. The happy couple and their guests, all members of the Lak ethnic group, were from the aul, or mountain village, of Kara. The night before the celebration, Kara’s city manager had received a message from several influential members of the village’s jamaat who live outside Dagestan but maintain strong connections with their hometown. The message included a list of suggestions for protecting Kara from COVID-19, and it also expressed special concern for older community members, who make up much of the population in Dagestan’s mountains. The jamaat advised the village government to follow World Health Organization (WHO) recommendations and cancel all large events. Usually, Kara’s leaders follow the advice they get from community members who have moved away: these native sons pay out of their own pockets to keep the aul afloat financially, and they often make important decisions without waiting for guidance from the government. Caucasian weddings are a special case, though: families spend many months planning each one, and guests often travel long distances to attend.

Some of them did change their minds after the jamaat members spoke out. Children and the elderly were asked to stay away from the March 27 wedding, so attendance was low by Dagestani standards: between 400 and 500 people. As each guest entered the banquet hall, they were sprayed with the disinfectant chlorhexidine and beamed with a contactless thermometer to have their temperature measured.

A source familiar with the proceedings told Meduza that attendees were especially happy to see a guest who had flown in all the way from Kaliningrad. After the marriage ceremony, the guest’s family members brought him back to Kara and introduced him to the local elders “to show him how long people live here in our town.” A lamb was slaughtered in the guest’s honor and all the neighbors invited to share in the meal. Only on his way out, when he arrived at the Makhachkala airport, did the guest start feeling severely ill. Nonetheless, he boarded his flight to Kaliningrad, where he was tested for the novel coronavirus. The test came back positive.

There aren’t any doctors in Kara, just a single paramedic. Nevertheless, the aul’s émigrés living all over Russia developed a detailed crisis plan, offering several possible approaches to stop COVID-19 from spreading in their hometown. Then, they had full-body PPE and oxygen machines delivered to the tiny village, which has a population of less than 500. Only the wedding guest’s three closest relatives, who had hosted him for the night, ultimately tested positive for COVID-19.

On April 3, 2020, the Lak District of Dagestan, which includes Kara, declared a quarantine. Special passes are now required for anyone traveling through the area. Working independently of the local government, Kara’s jamaat put its own anti-coronavirus measures in place. Every day, all of the village’s residents post their body temperatures in a shared WhatsApp group, and several times a week, a doctor and a group of volunteers decked out in PPE sanitize every home in the aul. Philanthropists and nonprofits arrange for food to be delivered to the village. Only four members of the jamaat have died of COVID-19 so far — all of them grew up in Kara but had moved to Dagestan’s larger cities before the start of the pandemic.

“No more than 15 or 20 percent of our doctors are at work”

Fifty-five-year-old neurologist Oleg Dibirgadzhiev returned from the big city to his home village in the Khunzakhsky District to work with COVID-19 patients. The district is mostly home to members of the Avar ethnic group.

“Right now, no more than 15 or 20 percent of our doctors are at work,” he told Meduza. “The rest are either sick or they’re under quarantine because of their age. There are almost no free beds. In the 11 days I’ve worked here, four patients have died, and six more have died who were sent to Makhachkala. And that’s just in our hospital. I’m sure that in the Khunzakhsky District [as a whole], with a population of 33,000, at least 7,000 are infected. Only confirmed cases get counted in the statistics, but the scale of this is unbelievable,” he said.

Magomed Musayev, the acting head physician of the Khunzakhsky Central District Hospital, said that by his count, nine percent of the facility’s clinical physicians are sick, 35 percent aren’t working because their age puts them at risk for COVID-19 complications, and 32 percent have continued to do inpatient work.

While Dibirgadzhiev’s estimate seems high when compared to Musayev’s official data, it does match up to the opinions of other experts. Ziyautdin Uvaisov, who leads the nonprofit group Patient Monitor, said in an interview with Meduza that “in a lot of villages [across Dagestan], a third or half of the population is sick. In some of them, three or four people die every day.” Medzhid Medzhidov, the mayor of a village called Tebekmakhi, said that of the settlement’s 2,150 residents, more than a thousand have “cold-like viral illnesses.” In March and April, Medzhidov said, twelve members of his community were buried, while a typical year only brings between 15 and 17 deaths.

According to Oleg Dibirgadzhiev, even more people might have died in the Khunzakhsky District if not for the actions of the local government’s coronavirus task force, which is led by the head of the district administration. The task force made sure that Dibirgadzhiev’s hospital had oxygen machines in time for a flood of patients to arrive. Volunteers and donors who provide food to those living in small villages have also made a difference.

“The system had degraded so much that wasn’t even capable of handling its normal workflow, let alone the pandemic,” Dibirgadzhiev said. “We were lucky to have this [district-level] administration. In other places, people have just been left by the wayside. Medical workers are dying. In the Gergebilsky District, which is right next to us, it’s a catastrophe. The lead physician has been replaced, and his deputy — she died. Their radiologist, who was a mother of four, died too.”

“If you’re prepared to die, come in”

Suleiman Kerimov is a wealthy entrepreneur and a federal-level politician, but he was born in the Dagestani city of Derbent, which has a population of about 126,000. Kerimov, who has represented Dagestan in the Federation Council since 2008, spent 1.5 billion rubles (approximately $20,415,000) out of pocket to equip hospitals in his hometown and across Dagestan for the pandemic. That’s about the size of the Derbent government’s total income for 2019. Even so, the city’s doctors have faced shortages of the most basic essentials.

“I don’t understand what exactly Kerimov sent us,” fumed Magomed, a doctor who asked that his name be changed for this story. He and a group of other dermatologists from Derbent’s skin and venereology clinic were redeployed on May 1 to the city’s pediatric infectious disease hospital, which has been reoutfitted to serve as a temporary hospital for pneumonia patients.

“We went in, and then we spent an hour in the staff room,” Magomed said. “There was no training, and for protection, there were just shoe covers and pants and gowns made of gauze. No respirators, no disposable suits. The doctors told us, if you’re prepared to die, come in. If not, run away as fast as you can, before we infect you! There was no red zone, no green zone, no gateways [separating virus-contaminated areas from uncontaminated ones]. We said we wouldn’t work under those conditions, and we left. Now, management is threatening to fire us. They’re saying we’re just scared, but the disease isn’t dangerous, and we can just go in there wearing normal clothes. Four doctors, including myself, have 38-degree fevers [100.5°F]. Seems like we’d already managed to get infected. Every day, they bring three or four bodies out of the infectious disease hospital. There are doctors I know in Karabudakhkent and Gergebil — we’re all dermatologists, so we have our own WhatsApp groups. They’re saying that for them, this is war, plain and simple. They don’t record deaths as COVID deaths because they can’t get people tested fast enough. They put it down as community-acquired pneumonia.”

The press service for Dagestan’s Health Ministry assured Meduza that all of Derbent’s infectious disease hospitals are equipped with gateways that allow for personnel to disinfect themselves when moving from one wing to another. However, we also obtained a recording of a meeting between the Derbent dermatologists and their lead physician that supports Magomed’s assertions. In the recording, the dermatologists mention that the infectious disease specialists who were supposed to be training them warned that their hospital had not been divided into contaminated and uncontaminated zones.

The nearby city of Dagestanskiye Ogni has seen similar reports. On April 29, Patient Monitor posted an open letter on Facebook from an ICU anesthesiologist working in the city’s hospital: “At the very beginning of the epidemic, the lead physician forced us to report to her administrators saying that our facility had heightened its preparedness for dangerous infections,” the letter asserted. “In reality, our supplies were in a state of destitution. The entire staff was working in homemade masks; management handed out 200 so-called anti-infectious suits for the sake of appearances, but the suits were nearly transparent and full of holes. Even then, we didn’t have shoe coverings, protective footwear, or respirators. We, the doctors, had to buy antiviral drugs ourselves, plus antibiotics for our colleagues, anesthetics, infusion solutions, suturing materials for the surgeons and OB-GYNs, gloves, rubbing alcohol, and a lot of other things. Every one of us spent 20,000 or 25,000 rubles (about $270 – $340). [...] The staff is slowly dying off. Our ‘lead physician’ hasn’t been showing up to work at all. We haven’t seen her for almost a month already — every once in a while, she shows up and locks herself into her office.”

The lead physician for Dagestanskiye Ogni’s hospital posted on Instagram denying the letter’s description of her work. She later deleted the post, but screenshots have been preserved in local news sources. Despite the lead physician’s arguments, Dagestan’s Health Ministry has announced an internal investigation of the hospital’s operations during the COVID-19 pandemic.

Ginger and apricots

Even at the height of a global pandemic, the streets of Makhachkala are busier than cities in neighboring regions were before COVID-19 began to spread. The boulevard that runs along the Caspian coast is blocked off with caution tape, but hurried beachgoers don’t even bother to go around it — they lift up the tape and go on their way. There are fewer people out soaking in the sun than there were in February, but the beaches are still dotted with volleyball players, swimmers, and martial artists practicing on the sand.

Minibuses have started running their routes less frequently. During the day, they tend to be empty, but they still fill up by evening. There are fewer cars on the streets, and police officers regularly stop drivers to ask for their quarantine passes. The remaining traffic has been replaced by bicyclists: before the pandemic, only the bravest among them dared to ride through Makhachkala’s packed throughways. The flow of pedestrians on the sidewalks has barely decreased, and only some of those pedestrians have been wearing masks or other protective gear.

“Nothing in my life has changed,” a merchant who wasn’t wearing a mask told us. “People are starting to feel bad because of all this self-hypnosis even though there’s nothing to be afraid of. I don’t believe in the coronavirus.”

Still, there are fewer “COVID skeptics” here with every passing day. Medication prices have multiplied. Shelves that used to carry drugs whose demand has shot up during the pandemic stand empty in pharmacies, Islamic shops, and even veterinary stores.

“Vetom? We don’t have any,” a cashier shrugged in response to our request for a veterinary immunostimulant. When we asked who bought the store’s entire supply, she said, “People. It wasn’t cats coming in. They’re buying it for themselves.”

Full-fledged fraud is part of the picture, too. In Izano, a town in the Akhvakhsky District, the local jamaat paid about 70,000 rubles ($953) for a mask delivery, but their contractor just took the money and disappeared, according to an anonymous source familiar with the situation.

Makhachkala’s City Hospital Number 1 and the Republican Infectious Disease Center are equipped relatively well. Saniat Magomedova, an associate professor at the Center, is currently hospitalized in one of its ICU units. She can’t speak, but she wrote to Meduza on WhatsApp that the facility has enough of all the medications it needs except for Actemra, which helps counteract extreme immune reactions to hospital treatment called cytokine storms. Actemra speculators have been selling the drug on WhatsApp for four times its usual price, but even they have had a hard time delivering the medicine to buyers. According to Magomedova, the situation in the Republican Clinical Hospital and its emergency medicine offshoot is significantly worse: most of the doctors there have gotten sick, she said. Dagestan’s Health Ministry denied those claims in a comment to Meduza.

Any Makhachkala resident who isn’t already hospitalized also can’t receive free CAT scans to determine the severity of their cases because the scans require a referral, sources told us. “As a rule, doctors aren’t doing home visits anymore,” explained a neurologist who asked to remain anonymous. “People have to go to private medical centers. The folks working on the front lines, in the red zones, they’re heroes. But the situation for other medical staff isn’t any better: we don’t know whether the patients coming to us are infected or not.”

Meanwhile, Makhachkala’s largest food market has been half-empty. Many of its booths are covered in large tarps. “They aren’t at work,” one of the remaining salespeople told Meduza. “The merchants are all sick with that flu.”

In March, a rumor flew around Dagestani social media groups that claimed ginger could be used to treat COVID-19. Ginger prices shot up to 2,000 rubles ($27) per kilogram. In April, the fervor died down. Now, the salesperson at Makhachkala’s market said, dried apricot is all the rage. A nearby fruit vendor suggested preventing infections by drinking diluted hydrogen peroxide, which is highly toxic. “The bacteria can’t survive in an acidic environment,” he said, though COVID-19 is not a bacterial disease.

Most of the stands at the market that don’t sell food have shut down. Only one clothing and footwear vendor is still open. The store has a piece of paper taped to the door that grants it permission to sell PPE, and a pile of black reusable masks is stacked next to the women’s scarves outside.

On the day before Victory Day, which is celebrated on May 9 to mark the Soviet Union’s role in World War II, Makhachkala’s government officials and entrepreneurs drove around the city bringing presents to veterans of the war. Meanwhile, volunteers bearing bags full of groceries but not wearing face masks took photos next to elderly people. Zelyonoye Yabloko (Green Apple), the grocery chain that evidently sponsored the latter project, ultimately deleted photos of the volunteers from its website, but critical posts about the maskless volunteers remain on Instagram. Meanwhile, the mayor of Makhachkala attempted to pay a congratulatory visit to World War II veteran Ibragim-Pasha Sadykov, who let the city leader enter his home only after an extended bout of door-knocking at the gate. The cautious veteran was afraid to receive visitors at the height of a pandemic.

The muftiate goes online

The first of Dagestan’s religious institutions to close in late March was the Derbent synagogue. On March 30 and 31, the Tangim and Ikhlas mosques followed suit: both mosques are Salafi and acted without waiting for orders from the local muftiate. On March 31, Dagestani Governor Vladimir Vasilyev recommended that religious institutions of every confession temporarily close their doors to worshippers. On April 3, he complained that about 1,000 people had still gathered for Friday prayers at Makhachkala’s central mosque, while about 3,000 attended prayers in Kizilyurt, an hour and change away. On April 10, the Muftiate of Dagestan called on the republic’s imams not to let more than 40 people into their mosques at any given time.

On April 15, Archepiscope Varlaam of the Makhachkala Diocese announced that all local Russian Orthodox institutions would be closed to the public and their services would be moved online. The following day, Dagestan’s head sanitary physician banned laypeople from attending any religious function at all. That order was immediately backed up with a command from the Spiritual Directorate of the Muslims of Dagestan to close the republic’s mosques. To replace collective in-person prayers, the muftiate’s Instagram account began streaming daily sermons and Quran readings. The Center for Islamic Medicine also closed down, leaving only a few private salons open to perform hijama, a medical cupping and bleeding technique.

The holy month of Ramadan began on April 24 for the Salafis and April 25 for the official muftiate. A few days earlier, the Spiritual Directorate posted a video on Instagram explaining that the daily fasting typically required during Ramadan would not be applicable to the sick, who could risk their health without adequate nutrition. Other Muslims were asked to drink fluids or take medications as directed by their doctors. Religious leaders also asked Dagestan’s Muslims to limit any funerals to family members rather than holding large memorial services as they would typically do. The bodies of Muslims who die of COVID-19 in Makhachkala now receive a traditional bath in a single designated mosque where employees wear extensive PPE. The imam at the helm of that mosque told Meduza that between five and 10 bodies are entered into his care on a daily basis.

On the muftiate’s official Instagram account, one religious representative gave viewers instructions on a traditional cure to use against COVID-19: honey, black caraway, vinegar, lamb broth, onion, and garlic. In early May, the Spiritual Directorate’s website announced that the mufti and his family had recovered from coronavirus infections.

Makhachkala’s Muslims would typically break their fasts at a Ramadan tent outside the central mosque. This year, volunteers have brought food to the needy on a daily basis instead. Muslim charities and philanthropists have also held fundraisers to fight the COVID-19 pandemic. One major foundation, Insan, raised two million rubles ($27,300) to buy PPE for hospital staff.

“They can just order the doctors to go in and die”

Many Dagestanis who don’t trust their republic’s official COVID-19 case numbers have tried to figure out the scale of their local pandemic independently by looking at reported cases of pneumonia. However, even that data is incomplete. The newspaper Dagestani Youth collected pneumonia statistics from ten rural districts and two urban areas throughout the republic and found that for every 211 positive coronavirus tests, there are at least 1,675 people who have had severe or even fatal cases of pneumonia. Dagestan’s Health Ministry told Meduza that seven cities (Makhachkala, Buynaksk, Derbent, Kaspiisk, Kizilyurt, Kizlyar, and Khasavyurt) and six districts (Botlikhsky, Gergebilsky, Karabudakhkentsky, Levashinsky, Untsukulsky, and Khunzakhsky) have registered the bulk of the republic’s community-acquired pneumonia cases.

In a conversation with Meduza, the regional Health Ministry acknowledged that it had been unprepared for the pandemic’s rapid spread. A representative from the Ministry’s press service explained that the agency initially acted on statistical models that didn’t take the region’s extremely low self-isolation rate into account. In an official letter sent to Meduza’s editors, the representative assured us that Dagestan’s deficit of PPE for medical workers has been resolved. The republic has obtained more than a million masks, 3,670 respirators, and 9,134 protective suits by drawing on its government’s reserve funds. The Ministry also wrote that infection rates among medical workers have only come in waves, and small ones at that; reports that the majority of personnel at some hospitals aren’t coming to work are false, it added. Ministry officials have promised hazard pay to all workers treating coronavirus patients or patients with so-called community acquired pneumonia.

At the same time, doctors and hospital administrators in individual Dagestani districts have continued to call for help on social media. “An acquaintance of mine in the Kizilyurt Hospital asked for donations to buy suits for the staff,” the anonymous doctor Magomed told Meduza. “The lead physician told her to delete that post and publish a denial. She refused. Now, people have raised enough to buy them 60 suits.”

In a recording obtained by Meduza, a Dagestani medical official attempts to persuade a group of doctors not to “bring the dirt out of the hut,” a phrase typically used to chide those who discuss domestic crises outside the home. “We don’t know who’s setting this up. They’re bringing shame first of all to our city on the region-wide level and then to Dagestan on the national level. We’ll be the ones to take the blame — we’re all one family. Nobody’s going to start naming names — people just need a provocation,” the official says.

“The farther a hospital is from Moscow, the worse shape it’s in,” said a federal nonprofit coordinator who asked to remain anonymous. “In Dagestan, and not only in Dagestan, there’s a massive lack of PPE, and doctors are being told to sew masks themselves. Even the [materials] that are being bought are then being stolen and sold. Here’s a real-life example for you: a village hospital in Dagestan asked our foundation for 1,500 protective suits, 3,000 masks, and some other odds and ends. It was obvious that they would end up on the black market. We automatically reject those kinds of requests. Usually, we get word of actual problems through messages from nurses that basically say ‘People, save us, we don’t have shit over here!’ We don’t get requests from lead physicians at all because they’ve all signed up to say their hospitals are fully equipped. If they’re facing up to the possibility of working with no staff, then they tend to sign the paperwork we need to make deliveries anyway. Still, wherever a lead physician has total power, they can just order the doctors to go in and die.”

Text by Patimat Amirbekova and Vladimir Sevrinovsky

Translation by Hilah Kohen