As a deadly cholera outbreak spreads in Syria, doctors, aid workers, and civilians in the rebel-held northwest are bracing for impact, worried that a shortage of clean water, cramped living conditions, and limited healthcare options will provide a fertile breeding ground for the disease.
As of 26 September, cholera has killed at least 36 people and infected a suspected number of around 6,000 across the country since President Bashar al-Assad’s Ministry of Health declared an outbreak earlier this month. The source of the outbreak — the first in Syria’s eleven and a half years of war — is believed to be the use of contaminated water from the highly polluted Euphrates River, both directly from the source and reportedly from trucks purporting to sell clean water.
Initially, cases were mostly limited to the northeast. But last week the outbreak crossed the war’s front lines. The rebel-held northwest — which is home to 4.4 million people, most of whom live in extreme poverty, worsened by inflation, rising food prices, and aid cuts — announced its first confirmed case. That number is now nine, although testing capacity is limited, so the real number may be much higher.
Duraid al-Rahmoun, head of primary care at the Idlib Health Directorate, the body that oversees hospitals across the province, fears the worst in a region where many people live in overcrowded and underserved camps, and the healthcare system is in bad shape.
“The outbreak of the disease in the [Idlib] region heralds a humanitarian catastrophe, both inside the camps and for the medical sector,” he told The New Humanitarian.
Around three quarters of the northwest’s total population have been forced to flee their homes elsewhere in the country at least once, and the UN estimates that some 1.7 million people in the region live in camps.
The majority of these people live in what Dr Amany Sadek, the WHO’s cholera outbreak incident manager, described in an email as “overcrowded and old tents with limited or no access to basic services, like water supply or proper sewage systems”. Given how cholera is contracted — through consuming water or food contaminated with the cholera bacteria, which often spreads through faecal matter — that’s a serious concern.
Al-Rahmoun said the outbreak will be “overwhelming” if it spreads through Idlib, “especially for those living in the camps, whose health is already at risk due to a lack of food and clean water… in addition to the dangers [posed by] open sewage”.
Ihab al-Saleh, a resident of al-Amal camp, near north Idlib’s Kafr Yahmoul village, said he knows he’s at risk of cholera, but that doesn’t make getting clean water any easier. Bottled water is an unaffordable luxury for many, so people like al-Saleh depend on aid groups trucking in or treating water. But not everyone is reached, and many are forced to rely on unsafe sources of water for their daily needs.
“Before we even heard about this cholera outbreak, we had many other waterborne diseases here,” al-Saleh explained. “Sometimes the water we drink is light brown. We try to boil it before we drink it, gathering twigs to light a fire.”
“We appealed to several organisations to find a solution to the sewage problem, but to no avail.”
That’s not to mention the open sewage that flows through the camp, and the fact that al-Saleh said he’d seen nearby farms “irrigating their vegetables with sewage water”.
“We appealed to several organisations to find a solution to the sewage problem, but to no avail,” he said.
Dr Muhammad al-Saleh, coordinator of the Early Warning Alert and Response Network (EWARN), said there are measures people can take to prevent cholera: washing hands, purifying drinking water, washing vegetables correctly, cooking food thoroughly, and not relying on food from unknown or unreliable sources.
But with so many people, like Ihab al-Saleh (no relation), living in camps without clean water, relying on food from fields irrigated by sewage, he said he was worried that “there’s nothing to prevent the spread of the outbreak”.
Iyad Agha, coordinator of the Northwest Syria NGO Forum, a group that coordinates international and Syrian aid groups working in the region, said camps like the one where al-Saleh lives are likely to be the parts of the northwest most vulnerable to the outbreak.
He doesn’t think fears of a catastrophe like those expressed by al-Rahmoun are overblown. “Unfortunately, it’s a real fear,” Agha said. “We do have a vast number of informal settlements [in the northwest], which are more exposed to cholera risks due to being close to raw sewage and open water like swamps.”
Battered health system
Cholera should be easy to treat, given proper supplies and medical facilities. But war-battered northwest Syria, which is controlled by the Sunni militant organisation Hayat Tahrir al-Sham — designated a terrorist group by many countries — has neither.
Dozens of hospitals and clinics in the region were bombed during a 2019-2020 offensive by al-Assad and his Russian allies against the rebels. Many have never been rebuilt, and others have been forced to close or operate at a reduced capacity due to funding cuts. WHO’s Sadek, who commented to The New Humanitarian via a spokesperson, said there are 536 healthcare facilities in the northwest, but only 318 are fully functioning, and “all are overstretched”. They don’t all have access to clean water.
For those who live in remote areas, just getting to the healthcare centres that are still open is an expensive proposition due to rising fuel prices and widespread poverty.
“The medical sector suffers from great fragility and is expected to collapse [if cholera spreads],” said al-Rahmoun of the Idlib Health Directorate, adding that he’s even more concerned, “in light of the threat of closing the Bab al-Hawa crossing to organisations operating in the region”.
Much of northwest Syria’s aid comes via the UN and NGOs it works with across the Turkish border, at a crossing called Bab al-Hawa. The UN is able to use this crossing without al-Assad’s permission because of a Security Council resolution that permits it. But with Russia, al-Assad’s key supporter and ally, a veto-wielding permanent member of the council, this resolution has become increasingly contentious.
In July, the permission expired when diplomats failed to agree on its renewal, and council members eventually capitulated to a Russian resolution that allowed access for only six months. It will be reviewed again then, but continued access is not a sure thing.
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Agha said NGOs involved in the cholera response had begun awareness-raising, but “healthcare in Idlib is already stretched, [and] funding gaps decreased their capacity further, [so] for the time-being organisations are working with their existing capacities to prepare, and have already requested additional funding.”
Sadek of the WHO said three treatment centres had been set up, with others on standby. “Some were COVID-19 isolation centres that were pivoted into treatment for cholera, particularly in areas where we’ve received alerts over the past 10 days,” she added.
There are currently enough cholera kits to treat 1,000 cases in the northwest. The WHO expects to have more kits — enough to treat 1,500 cases — in the next two weeks and has requested another shipment that would treat 7,000 more.
Sadek said aid workers “have been mobilising to prepare and respond to any outbreak in the northwest”, and the first case — in Aleppo province’s Jarablus district — was contained effectively thanks to community engagement and the distribution of water purification tablets.
But the key challenges, according to Sadek, remain: “Poor sanitation conditions and the lack of sufficient funds to improve water, sanitation, and hygiene infrastructure in northwest Syria.”
With additional reporting by Annie Slemrod. Edited by Andrew Gully.