(CNN) In the nearly two years since the pandemic began, Turkmenistan has not seen a single case of Covid-19.
Or at least, that's what the central Asian country's secretive, authoritarian government claims.
Turkmenistan, a former Soviet republic home to nearly 6 million people, is one of at least five countries that have not reported any coronavirus cases, according to a review of data collected by Johns Hopkins University and the World Health Organization. Three of those are isolated islands in the Pacific and the fourth is North Korea, a tightly-controlled hermit state.
Turkmenistan's repressive President Gurbanguly Berdymukhamedov, who has ruled since 2006, has dismissed reports of Covid-19 in the country as "fake" and told the United Nations in an address Tuesday that the response to the pandemic shouldn't be "politicized."
But independent organizations and journalists and activists outside Turkmenistan say there's evidence the country is battling a third wave which is overwhelming hospitals and killing dozens of people -- and warn the President is playing down the threat of the deadly virus in a bid to maintain his public image.
Ruslan Myatiev, an exile from Turkmenistan and editor of the Netherlands-based independent news organization Turkmen News, said he has personally assembled the names of more than 60 people who he claimed have died of Covid-19 inside the country, including teachers, artists and doctors.
Myatiev said he has verified all the recorded deaths with health records and X-rays, revealing severe lung damage and medical treatment consistent with coronavirus victims.
"Instead of accepting it and cooperating with the international community, Turkmenistan decided to stick its head in the sand," said Myatiev.
The Turkmenistan government did not respond to CNN's requests for comment.
As Covid-19 spread around the world at the start of 2020, Turkmenistan insisted it had no cases, even as bordering countries reported skyrocketing outbreaks.
Iran, with which Turkmenistan shares a long land border, has reported one of the world's largest Covid-19 outbreaks with nearly 5.5 million total cases, according to the World Health Organization (WHO).
"You look at what's happening at other countries in the region and how different could Turkmenistan possibly be?" said Rachel Denber, deputy Europe and Central Asia director at Human Rights Watch.
According to the websites of the British and Australian foreign ministries, all flights into Turkmenistan are currently suspended and only Turkmen citizens are allowed to enter the country.
Myatiev said his sources in Turkmenistan began contacting him about cases in around May 2020 -- about the same time Covid-19 was spreading around the world. He said the first messages he received talked about a "weird lung disease, flu-like" which was affecting many people.
"It was at least 40 degrees Celsius outside (104 degrees Fahrenheit) -- not a usual flu season," he said.
In June 2020, the US embassy in the capital, Ashgabat, issued a heath alert warning of "reports of local citizens with symptoms consistent with Covid-19 undergoing Covid-19 testing," and being placed in quarantine for up to 14 days.
The Turkmenistan government immediately called the statement "fake news."
A WHO mission to Turkmenistan in July 2020 did not confirm any coronavirus infections inside the country but did say it was concerned about "increased numbers of cases of acute respiratory infection and pneumonia."
One WHO official said Turkmenistan should act "as if Covid-19 was circulating."
By then, the situation was out of control, according to Myatiev. The government advised citizens to take bizarre public health measures, such as eating a particular type of spicy soup.
In January this year, Turkmenistan announced it had approved Russia's Sputnik V coronavirus vaccine for use in the country. Then in June, the World Bank agreed to lend $20 million to the Turkmenistan government, mostly for health facilities and construction, as part of a program to "prevent, detect and respond to the threat posed by Covid-19."
As recently as Tuesday, President Berdymukhamedov said the efforts of the global community in addressing the Covid-19 pandemic were "insufficient," although he did not mention the situation inside his own country.
"The pandemic has exposed serious systemic failings in the international response to this challenge," he said.
Despite Berdymukhamedov's claims that his country his Covid-free, the reality inside Turkmenistan is starkly different, according to independent journalists and activists.
Diana Serebryannik, director of Europe-based exiles group Rights and Freedoms of Turkmenistan Citizens, said her organization had heard from contacts in the country that hospitals there are currently struggling to deal with the influx of cases.
Serebryannik said Turkmen doctors from her organization who were now living overseas were in touch with their former colleagues in the country, allowing them to find out the real situation and provide advice.
She said doctors inside Turkmenistan had told her both oxygen and ventilators were hard to come by in the country, treatment was expensive and deaths from the virus could be in the thousands.
"Turkmenistan is burning, it's burning with Covid ... Sometimes they do not even accept patients to the hospital, they just send them home," she said.
According to Serebryannik, the official cause of death in these cases is not listed as Covid-19 or even pneumonia -- instead medical certificates record a separate condition, such as a heart attack, she said.
When health workers have tried to speak up about the reality on the ground, they have been pressured into silence, according to non-profit Human Rights Watch.
Inside the country, freedom of the press and independent scrutiny is not allowed -- Turkmenistan was ranked 178 out of 180 countries and territories on Reporters Without Borders 2021 World Press Freedom Index, just above North Korea and Eritrea.
Turkmen citizens who peacefully criticize the government have faced severe punishments, according to Human Rights Watch, including reports of torture and disappearances.
Foreign residents have also been affected by the Turkmenistan government's coronavirus denials. In July 2020, Turkish diplomat Kemal Uchkun was admitted to hospital in Ashgabat with Covid-like symptoms but was refused permission to evacuate to his home country, according to the journal of Asian Affairs.
According to the BBC, X-rays sent to Turkish hospitals by Uchkun's wife were confirmed to show evidence of Covid-19.
The journal of Asian Affairs said Uchkun died on July 7. His official cause of death was heart failure.
Most recently, Myatiev said he had confirmed the death of a 61-year-old Russian language and literature teacher, who had been in hospital since August, according to Turkmen News.
Multiple authoritarian governments around the world have announced their Covid-19 outbreaks and received international assistance, including China, the earliest country affected.
So why is Turkmenistan so insistent that it has still not seen a single case?
Both Myatiev and Serebryannik said it was down to President Berdymukhamedov who, as a dentist by profession and former health minister, had placed great emphasis on effectively governing the well-being of his people -- at least in principle.
Serebryannik said Berdymukhamedov, 64, wanted to appear like a savior to the country, and an impressive world leader, by keeping Covid-19 out.
"Turkmenistan is a country where everything in the garden looks rosy ... you have those marble, state of the art (health facilities) equipped with German, French, Japanese, whatever, equipment," journalist Myatiev said.
Admitting the presence of a deadly virus would undermine the idealized image the President has created and leave Berdymukhamedov open to criticism -- and potentially to being held to account.
"It would be someone's failure, someone would have to bear responsibility for that and who has the ultimate word for that? The President," Myatiev said.
There has been no indication yet that Turkmenistan is preparing to reverse its position and admit to having Covid-19 cases inside the country, but Serebryannik said she believed the government would have to eventually.
She said there had just been "too much death."
Human Rights Watch's Denber said international organizations interacting with Turkmenistan, including WHO, had a duty to be honest with the world about the situation inside the country.
"At a certain point you have to say at what cost are you protecting that presence (in the country)? Are the measures you're taking to protect your relationship ... undermining your core mission?" she said.
Denber said in a global pandemic, with many outbreaks linked across international borders, nations had an obligation to provide accurate testing and correct public information.
"We're all interconnected," she said. "When one of us fails, we all fail."