Jana al-Issa | Hassan Ibrahim

Amidst circumstances that seemed “very favorable” for the spread of a deadly outbreak in war-torn Syria, the cholera re-spread in early September, more than 13 years after the last cholera infection recorded in 2009.

With the hike in deaths and infection cases along the Euphrates River in the countryside of Aleppo, al-Hasakah, and Deir Ezzor, several local and international bodies confirmed that the main reason for the spread of the disease in the region is the low water level of the river and the sewage that flows into it, as well as using polluted water in irrigation.

Real fears of the disease’s spread, with the concern of reaching the “worst scenario,” and its impact on the population in a country whose sectors have been drained by the war, most notably the medical one, amid weak capabilities and a decline in the number of specialized medical personnel throughout Syria.

There is no indication on the horizon that the governing authorities will be able to find permanent solutions that prevent the spread of the disease or the development of the situation into an epidemic or pandemic that threatens even neighboring countries, while the emergency measures were limited to prevention advices first, then temporary solutions to lessen the outbreak.

Enab Baladi discusses the extent of the cholera outbreak in Syria, its causes, and prospects for spreading, in addition to the nature of the measures taken to contain the disease or the attempts to stop its causes by local or international organizations operating in the region.

From Syria, cholera knows no borders

According to the latest statistics issued by the Early Warning and Response Program for Epidemics (EWARN) in Syria, as of Saturday evening, 24 September, the number of cholera cases in northeastern Syria reached 2,821, while the number of deaths as a result of the disease reached 15 deaths.

In northwestern Syria, one infection has been recorded since the outbreak began, according to data released by the program.

The regime’s health ministry said on Monday, 26 September, the cholera outbreak in several regions of Syria has killed 29 people in what the UN has called the worst outbreak in the war-torn country for years, according to Reuters.

Rapid assessment testing confirmed 338 cases since the outbreak was first recorded last month, with the bulk of deaths and cases in the northern Aleppo province, the ministry said in a statement.

It said 230 cases were in Aleppo province, where 25 people were confirmed dead. The rest were spread across the country.

Cholera is an acute diarrhoeal infection caused by ingesting food or water contaminated with the bacterium Vibrio cholera. Cholera remains a global threat to public health and indicates inequity and lack of social development. Symptoms: Cholera is an extremely virulent disease that can cause severe acute watery diarrhea. It takes between 12 hours and five days for a person to show symptoms after ingesting contaminated food or water. Cholera affects both children and adults and can kill within hours if untreated. Most people infected with V. cholerae do not develop any symptoms, although the bacteria are present in their feces for 1-10 days after infection and are shed back into the environment, potentially infecting other people. The World Health Organization

According to a statement issued by the World Health Organization (WHO) on 21 September, the spread of cholera, which is currently restricted to Syria only, has reached the outbreak stage.

During a press conference attended by Enab Baladi, the representative of the WHO in Syria, Dr. Iman al-Shanqiti, said that infectious diseases know no borders and may spread everywhere, and no person is protected from them, and this has been proven by the Covid-19 pandemic during the past two years.

What is the difference between an outbreak, an epidemic and a pandemic?

According to the WHO’s classification of terms of the spread of infectious diseases, a disease is classified as an outbreak when the number of infections exceeds the number usually expected. In this case, there is no specific number for the number of infections, as this varies according to the causes of the disease and the size and type of previous exposure to the causes.

While the organization defines an epidemic as the occurrence of disease cases in a particular community or region, or a specific health-related behavior, that clearly exceeds normal expectations.

According to the organization, the difference between an outbreak or an epidemic is not very clear, but the term “outbreak” is usually used when diseases occur in a limited geographical area, while if a disease spreads quickly to a larger number than experts expect, and moves to a large geographical area, it is often called an epidemic.

While the term pandemic indicates the spread of a disease, when the epidemic spreads all over the world, or over a very large area, and crosses the borders of a country, and a large number of people are infected with it.

Cholera may be endemic to Syria

Dr. Aula Abbara, a consultant in infectious diseases in London and co-chairs the Syria Public Health Network, told Enab Baladi via email that given the bad situation with regard to water in Syria due to the conflict, drought, lack of rainfall, and the damage to the water infrastructure, this raises concern that cholera will turn into an epidemic, and it may extend beyond the borders of Syria.

Abbara added that the conditions associated with the armed conflict in Syria, the forced displacement of millions of people, and the damage to water and electricity, in addition to targeting health facilities and stopping water treatment plants, contribute to the aggravation of the health situation that could lead to an epidemic.

The director of the vaccine program at the Support Coordination Unit in Syria, Dr. Mohammad Salem, said, in turn, that Syria is facing a “large wave” of a “cholera outbreak,” adding that as the infection continues to spread and move to new areas, the situation will worsen.

Salem warned, in an email to Enab Baladi, that in light of the current infrastructure conditions, it is expected that we will be facing a case of “cholera endemicity” in Syria, meaning that it could turn into an endemic disease.

What is an endemic disease? In epidemiology, the endemic disease is defined as a situation in which the outbreak of a disease is epidemic and is constantly present but is limited to a specific area, as this makes the disease spread and its rates expected. According to Dr. Mohammad Salem, in this case, the disease will continue to afflict the poor in successive waves, separated by varying periods of time, which will increase the burden on the health sector and the economic situation in the country as it will affect the tourism sector and commercial movement as well. The groups most affected by the disease in its endemic state are the chronically ill and malnourished, and the death rate is higher among them, adding that most Syrian children suffer from malnutrition, according to Dr. Salem.

Who opened the door to cholera?

During the war years, many Syrian cities and towns, with different forces and parties controlling them, experienced a drinking water crisis.

The most important reasons were the pollution and poor quality of water transmission pipes, the mixing of some drinking water with sewage water, in addition to the destruction of the infrastructure of water networks, and the damage and their being out of service.

The water crisis resulted in great damage, starting with the population, who were exposed to many diseases and epidemics, and damage to crops and animals.

Many people inside Syria depend on unclean water sources, which may lead to the spread of dangerous diseases transmitted by polluted water, in addition to the shortage and scarcity of water, which forces the people to resort to mechanisms and solutions that are not subject to the minimum elements of control and safety.

How does cholera infection occur?

Once infected, the patient sheds the germs in his stool for 7-14 days, so the infection can spread quickly, and the germs can remain in a small number of patients indefinitely without causing any symptoms, and these people are called carriers.

The most important ways of transmission of infection:

 – Food or water (drinking or cleaning water) contaminated with the feces of the infected person.

 – Vegetables irrigated with sewage water.

 – Raw or undercooked fish and seafood caught in waters contaminated with sewage.

 – Touching contaminated surfaces, especially in shared toilets.

 – Direct contact with infected patients and the use of their personal tools.

There are factors that increase the risk of spreading the disease:

 – Crowded living conditions and crowded communities, when people do not have access to clean water, waste collection is not available, and proper latrines are not available, so cholera represents a serious risk in the aftermath of a natural disaster or during wars and armed conflicts, due to the destruction of infrastructure or lack of public services or displacement of people and their concentration in camps.

 – Use of sewage water to irrigate land and crops.

 – Sewage flowing into rivers, lakes, and ponds.

 – Absence of sewage networks or lack of maintenance, and water leakage from them to drinking water networks.

Polluted water everywhere

The problem of water pollution in Syria is not new, but during the past years, it has not been accompanied by governmental solutions to preserve the health of the population and the cleanliness of crops from pollution. Recently, cases of contamination of water sources have been repeated, and analyses conducted on the waters of the Euphrates River have proven the presence of Vibrio cholerae strains.

The joint head of the Health Authority in the Autonomous Administration of North and East Syria (AANES), Juan Mustafa, said during a press conference on 21 September that many areas of the Euphrates River have turned into swamps, in addition to the contamination of vegetables irrigated with its water with germs as a result of the receding water in the Euphrates.

Since August, complaints, and quarrels have escalated due to the chaos and pollution caused by the re-operating of the Tal Salhab Sugar Factory, in the countryside of Hama governorate, as a result of the negative effects that the plant has on the agricultural and animal sectors related to fisheries.

The water from the factory, which flows into the Orontes (Asi) River, led to the death of large quantities of fish and the damage to the crops irrigated with the river’s water.

The incident was met with disregard from the regime’s government, and it was reported by the Director of Plant Production in the General Authority for the Development of the Forest, Wafik Zaroof, that the manufacturing period in the plant continues.

Last January, the director of the environment in Homs governorate, Talal al-Ali, said the water of the Orontes River was also polluted as a result of throwing sewage and waste of industrial facilities and medium industries located on the river, such as the fertilizers plant and the Homs oil refinery.

With the knowledge of the regime’s agriculture ministry, farmers in the Eastern Ghouta suburbs near the capital resort to irrigating their crops with sewage water due to the lack of irrigation methods that provide clean water.

The director of agriculture in Damascus countryside, Irfan Ziada, justified this in June 2021 by saying that some farmers sometimes use water mixed with sewage due to the damage to large numbers of wells that were relied upon to secure unpolluted watering devices.

In October 2021, Damascus witnessed 1,200 cases of water poisoning as a result of water pollution in the areas of Najha, Khirbet al-Ward, and the police housing in Damascus countryside due to the presence of a polluted private water source in Khirbet al-Ward, as roving cars fill water from it and sell it to citizens, according to the health director in Damascus governorate, Dr. Yassin Nanous.

The northeastern governorate of al-Hasakah suffers from intermittent drinking water cuts, forcing people to search for alternative solutions to transport water through uncontrolled trucks.

Diseases not surprising, water is a war weapon

Fears are mounting about the spread of cholera, and the increased risk of its spread in Syria on several occasions, as water sources are still contaminated in a number of areas.

Dr. Aula Abbara, a consultant in infectious diseases in London and co-chairs the Syria Public Health Network told Enab Baladi that the Syrian territories are currently subject to various regional control bodies.

This has led to the neglect of the water infrastructure and its quality, noting that the treatment of water and sanitation in Syria is a matter that has become urgent, she added.

The outbreak of water-related infectious diseases in Syria is not surprising, Abbara said, pointing out that there is poor planning with excessive exploitation of groundwater, even before the outbreak of the war in Syria, which is accompanied by drought, delay, and lack of rainfall in the winter, heat waves, and water pollution, and out-of-service water stations. All these conditions affected the quality and availability of water, she assured.

Salma Daoudi, a researcher specializing in health security and international relations at Oxford University, believes that the social, political, and economic context that Syria is currently experiencing has almost inevitably contributed to the environmental deterioration that led to the spread of cholera.

What explains the failure of the authorities to take preventive measures or moves is the lack of capacity and equipment on the one hand, and the lack of political will on the other hand, according to Daoudi.

Syria’s hydrology has undergone profound changes over the decades due to mismanagement, climate change, intensive water use, and increasing competition for water across international borders.

Overexploitation, depletion of freshwater resources, and water pollution by mercury and lead are all causes of environmental degradation that are difficult to address.

Water was used as a war weapon at the peak of the conflict, the health security researcher believes, saying water systems were deliberately targeted on an ongoing basis, proper maintenance was not carried out, and in some cases, facilities lost between 30 and 40% of the necessary technical and engineer staff responsible for maintaining the functioning of systems, whether through death, injury, forced displacement or imprisonment.

“The use of water as a weapon to regain control of the areas is taking place today as a political tool to pressure the Syrian people, as well as a reward for regime loyalists through politicized reconstruction in the regime-held areas.” Salma Daoudi, a researcher specializing in health security and international relations at the University of Oxford

Authorities late in announcing the disease for “sovereign” reasons

The authorities in Syria, whether the government of the regime or the Autonomous Administration of northeastern Syria, did not announce the spread of cholera or the registration of infections in its areas of control until several days after the news of the disease was circulated informally among the population, or through leaks by working people in hospitals.

Dr. Aula Abbara considers that the authorities’ handling of epidemics in the media can happen in many countries, as they do not want to announce the outbreak of the disease for fear of political repercussions and impact on the population.

Additionally, poor coordination among the many authorities operating in Syria may make publicizing the spread of the disease more difficult than necessary.

The epidemiologist confirmed that concern about the delay in declaring the outbreak of the disease may lead to a delay in activating the ability of organizations that are able to respond quickly, which results in a further spread of the disease, especially in areas where water and sanitation are poor.

She added that the faster the authorities announced the outbreak, the faster the response could be activated, which means an opportunity to stop the spread.

The public health sector was weak in Syria before 2011, despite the establishment of surveillance systems, which in turn were able to detect cases, says Dr. Abbara.

However, the public health response is still affected by the fragmented health system in Syria, where different geographical areas are under different sides of political control, and this, in turn, negatively affects the management of disease outbreaks, as infectious diseases do not respect regional or country borders, she added.

For her part, Oxford researcher Daoudi said that the politicization of health and its use as a weapon of war by various actors, such as repeatedly targeting hospitals, ambulances, and health workers, has led to a severe weakening of health capacities and created politically fragmented health governance, which has thus become an area for competition and gaining sovereignty.

Daoudi considered that the failure to contain the outbreak of epidemics directly questions the sovereignty and legitimacy of the regime and its ability to exercise complete control and exposes its failures, which creates a desire to conceal the true extent of the spread of a particular disease.

She gives an example that during the spread of COVID-19, there were many reports of a significant lack of announced cases due to limited testing capabilities and also due to a lack of political will.

The spread of cholera contradicts what the Syrian regime declares that Syria is safe for return.

“The Syrian regime uses the same political strategic logic with the outbreak of cholera, as it is afraid to show its economic and political weakness, and its inability to provide basic social services, such as water and health care to the population,” says Daoudi.

The regime fears the international community’s knowledge of the possibility of the epidemic spreading outside the Syrian borders due to the strict measures other countries may take to limit the epidemic, which may have adverse economic effects, according to the researcher.

Substandard capabilities

A medical reality that suffers, obstacles exist

The medical sector in Syria suffers from a lack of medical supplies and resources, as the medical sector in Syria has received its share of bombing, destruction, and attacks like other sectors, in addition to the direct targeting of medical personnel in various Syrian regions, and the targeting of the infrastructure of medical facilities.

The sector was also affected by the drop in wages in light of the conditions in the country.

Many relief organizations and local authorities appeal to external parties and medical and humanitarian organizations to provide the minimum requirements for treatment with each outbreak of diseases and epidemics as a result of various factors, amid the lack of permanent solutions and the absence of emergency or temporary solutions by the authorities controlling various regions in Syria.

On 19 September, the World Health Organization (WHO) said a plane with around 30 tons of supplies to support health authorities in dealing with the spread of a deadly cholera outbreak landed last Monday in the capital of Damascus.

Ahmed al-Mandhari, WHO’s regional director, told The Associated Press in an interview during a visit to Damascus that Syrian health authorities are coordinating with the international organization to contain the outbreak.

“It is a threat to Syria, to the region, (to) neighboring countries, and to the whole world,” he said.

Al-Mandhari said WHO is working on strengthening surveillance to identify cases and give the sick the proper treatment as well as trace those who are infected and those who were in contact with them, AP reported.

WHO’s regional director said the supplies will be equally distributed depending on needs, including in areas in the rebel-held northwest and northeast controlled by the US-backed Kurdish-led fighters.

Al-Mandhari said 55% of health care facilities are not functioning in Syria, and about 30% of hospitals sometimes do not function because of a “lack of electricity, which pushes them to use generators, which is not sustainable.”

He added that many Syrian health workers have left the country over the years, leading to a lack of staff to run different services.

“The health situation in Syria is really very difficult. It is very challenging,” Al-Mandhari said.

Al-Mandhari, who warned of the need to prepare for the “worst scenario,” had previously met, on 19 September, with the President of the Syrian regime, Bashar al-Assad, with the aim of “improving the reality of the health response, whether in terms of combating epidemics and diseases or technical support with medical equipment and tools,” according to what was reported by the Syrian Presidency account on Facebook.

Policies to address the outbreak

Only “temporary” solutions, permanent ones need a “regional solution”

Dr. Abbara believes that all organizations responsible for water, sanitation, infrastructure, and health need to work together to ensure that there is sufficient water of the right quality and quantity for the population as one of the available solutions amid the outbreak.

The consultant in infectious diseases added that there is also a need to treat water with chlorine to stop the spread of cholera among the population, and health workers need to work and cooperate to identify patients early and isolate them to prevent the spread from person to person through strict measures to prevent infection and promote good health in communities.

Abbara stressed the need to stop targeting water stations and their purification and treatment facilities, which have been subjected to many damages in various regions of Syria.

Salma Daoudi, a health expert of Oxford University, put forward some available solutions to limit the spread of the disease at the present time:

1. Strengthen monitoring systems to diagnose and track cases.

2. Announcing the real cases infected with this disease.

3. Ensure that humanitarian aid and medical supplies are distributed throughout the country, including in northeastern and northwestern Syria, and that this aid is not subject to the regime control, which may impose obstacles on its delivery to some areas, as a pressure tool on the opposition.

4. Adoption of water treatment policies, including chlorination of water supplies and disinfection of water filling points.

5. Civil society should raise awareness of the symptoms of the disease, its transmission methods, and the preventive measures that must be taken to reduce its spread.

6. Addressing the root political causes.

“Political consensus” may be a permanent solution

Regarding the possibility of finding permanent solutions to obtain clean drinking water and the extent to which they are achieved in Syria, Dr. Aula Abbara believes that this step requires careful planning across all geographical areas to draw a map of access to water and its availability.

Abbara asserted the need to stop practices that harm water by all parties and to hold accountable those who cause damage to water and electricity stations.

The consultant in infectious diseases said the quantity of drinking water transported by pipes of sufficient quality and that is available to the population in all parts of Syria varies according to the geographical location, given the effects of the conflict on different regions, noting that some people are currently obtaining drinking water by different means, including transporting water in trucks (which is expensive and inefficient).

The researcher Salma Daoudi explained that there are several levels to address the water shortage in Syria, the most important of which is making tangible changes in the political, social, and economic context, and the second depends on regional cooperation.

Securing clean drinking water requires repairing water infrastructure, including water treatment facilities and sewage systems, while humanitarian organizations are involved in efforts to rehabilitate some pumping stations temporarily, and any long-term solution depends on concrete changes in the political, social, and economic context, according to Daoudi.

Since the source of pollution is mainly the Euphrates River, Daoudi says there are regional dimensions to consider as well, as the controversial construction of some dams and large irrigation systems has caused severe water shortages, and increased tensions between Turkey, Iraq, and Syria, and therefore the management of solutions depends in the end on regional cooperation.

Prevention and control

According to the WHO, a multifaceted approach is a key to controlling cholera and reducing deaths. A combination of surveillance, water, sanitation and hygiene, social mobilization, treatment, and oral cholera vaccines are used.

In the event of a cholera outbreak in an area, the following precautions must be followed:

Cook food well and heat properly to kill germs.

Do not eat exposed foods or from street vendors.

Do not eat raw or undercooked seafood.

Wash fruits and vegetables well and rely on those that can be peeled.

Wash hands thoroughly with soap and water for at least 15 seconds, especially after getting out of the bathroom and before eating.

Clean shared toilets with chlorine frequently.

Boil your drinking water for at least a minute, if not chlorine-sterile.

Avoid using tap water and water fountains directly and prefabricated ice cubes. This advice applies to drinking water and water used to wash dishes, prepare food, and clean teeth.

Avoid direct contact with anyone showing symptoms of infection.

Sterilize all contaminated substances (such as clothing, sheets, etc.) that come in contact with cholera patients by washing them with hot water and chlorine if possible.

Wash and sanitize your hands if you come in touch with cholera patients, their clothes, or objects with chlorinated water or other effective antibacterial substances.

Get vaccinated as the cholera vaccine is available to people between the ages of 18 and 64 if they intend to travel to areas where this infection occurs.