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The cholera outbreak in northeast Syria: water, conflict and humanitarian challenges

By guest contributors: Neil J. Saad, Naser Almhawish, Aula Abbara

Over the last few months, cholera outbreaks have increased globally. The current outbreaks occur in contexts affected by natural disasters, such as the flooding in Pakistan, poor water and sanitation, or conflict and humanitarian crises, such as in Syria. Moreover, from Syria, cholera spread to Lebanon, a country currently in a severe economic, political and health crisis. In addition, these outbreaks occur against the backdrop of a global economic downturn and increasing fuel costs due to war in Ukraine, which complicates response efforts1.

Countries which did not report cholera in recent memory, including Syria, are now experiencing large-scale outbreaks 2. Given the breakdown of water, sanitation, hygiene (WASH) and healthcare after more than a decade of protracted armed conflict, large-scale outbreaks are, sadly, not unexpected.

Syria descended into protracted armed conflict after peaceful demonstrations in March 2011 were violently suppressed by the Syrian government. Since then, more than half the pre-conflict population of 22 million have been forcibly displaced; this includes 6.9 million as internally displaced people (IDPs) many of whom survive in suboptimal conditions with poor access to appropriate shelter, overcrowding and inadequate WASH 3,4.

Outbreak of cholera in Syria

In August 2022, an increase in acute watery diarrhoea cases were reported but it was not until 10th September 2022 that the Syrian government declared an outbreak 5. As of 16 January, a total of 77,561 suspected cholera cases have been reported in the whole of Syria. Of these, 50% (38,942) occurred in Northeast Syria 6. This area was also previously controlled by the Islamic State in Iraq and Syria (ISIS) and parts are currently under Syrian government or the Kurdish-led Syrian Democratic Forces (SDF) control while some areas are occupied by Turkey 7.

Several formal and informal IDP camps are located within northeast Syria often with limited access to sufficient quality or quantity of water placing people at higher risk of contracting cholera. Of these the Al Hol camp is the largest and the overall situation inside this camp is appalling. The security situation is violent and extremely precarious, which limits humanitarian operations and healthcare 8,9. People in IDP camp settings across northeast Syria are incredibly vulnerable to the spread of cholera and should be among key groups targeted in prevention and response efforts.

Safe water shortages and attacks on water infrastructure

Cholera is spread faeco-orally through the ingestion of contaminated food or water. Reasons for insufficient quality and quantity of water in Northeast Syria are multifactorial. First, as a result the climate crisis, there are falling groundwater levels, lower than expected rainfalls, drought and reduced flow in the Euphrates River, an essential water source for Syria that flows through Turkey, Syria and Iraq 10. The use of inadequately sterilised water from the river as well its use for crop irrigation is likely to have contributed to the spread of cholera. Second, the decade-long conflict has resulted in extensive damage to the urban and critical infrastructure including for water and sanitation 11. Third, there has been deliberate interference WASH by various parties to the conflict. The Alouk water station, which supplies around 460,00 people in Hassakeh governorate directly and provides trucked water to another half a million, has been interrupted either partially or completely by both Turkey and Syria numerous times over the last few years 12–14.

Furthermore, the additional health impacts of cholera and frequent interruptions of water and sanitation in an already vulnerable population result in an overall increase of waterborne diseases, such as hepatitis, and skin and soft tissue infections. It also has wider impacts on general health, including malnutrition, impaired immunity, and development delay, particularly in children aged under 5 years 15,16

Health and humanitarian challenges

Both local and international humanitarian organisations have sought to respond to the cholera outbreak with a focus on improving water and sanitation, including chlorination, the opening of cholera treatment centres and units, and community engagement and awareness raising 17–20.

However, several factors complicate response efforts, which could affect control of the outbreak. First, there is a vast underfunding of the response with other competing priorities for the population and a health system already adversely affected by the protracted conflict 19. Second, the closure of Yaroubieh border crossing has restricted health and humanitarian supplies to Northeast Syria, as seen previously during the COVID-19 response 21. Third, healthcare to the population is further impeded by challenges in access due to ongoing insecurity, requirement to travel long distances, and inability to afford transport or care. Fourth, despite efforts by various actors to engage in risk communication and community engagement, building trust among a community which has faced conflict related violations remains challenging 6,17,18. Lastly, though 2 million doses have arrived in Damascus and vaccination campaigns began in December 2022, they are not of sufficient quantity to meet the needs and mistrust of authorities could lead to low uptake 22,23.

Moreover, the ability to detect and respond to outbreaks is impeded by political barriers and the existence of subnational health systems functioning within its borders, often with little communication between them. In addition, the overall security situation in the northeast of Syria is a major impediment to outbreak surveillance, and prevention and response activities. The presence of the SDF and governments of Syria and Turkey, which all control various parts of the northeast, as well as ISIS sleeper cells creates a volatile security situation that limits supply, medical care, information sharing, and movements of health personnel or people affected by cholera 7.

Ways forward

The cholera epidemic in Syria is another symptom of a persistent deep-rooted issue. Better access, more vaccines, and enhanced surveillance are needed to control the current outbreak. In the long-term, improved infrastructure, respect for humanitarian law, and an end to the conflict should be envisaged. In addition, lessons learned are necessary as future outbreaks in the area are highly likely. While attention globally is elsewhere, the epidemic in Syria is another reminder that without addressing long-term needs, acute crises will continue to occur, affecting millions in the process. Global awareness and assistance are needed for many globally, but particularly in Northeast Syria.

About the authors

Dr Neil Saad is an epidemiologist and an expert in humanitarian health. He is a Visiting Fellow at Hughes Hall, University of Cambridge. He has worked for several years in humanitarian crises and conflict settings with Médecins Sans Frontières/Doctors Without Borders and the United Nations in the Democratic Republic of the Congo, Cambodia, Bangladesh, Syria, Jordan and the occupied Palestinian territory.

Dr. Naser Almhawish is a Syrian surgeon, experienced surveillance officer, public health specialist, and consultant who supports the Assistance Coordination Unit, Gaziantep, Turkey. He holds an MPH and has wide experience in communicable disease surveillance in the region.

Dr. Aula Abbara is an Infection and Acute Medicine Consultant at Imperial NHS Healthcare Trust, and honorary clinical senior lecturer at Imperial College

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.


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