As winter arrives in Syria – a country already grappling with fuel shortages, severe poverty, and more than 11 years of war – Idlib’s healthcare workers are braving the cold, trying to slow the spread of a months-long cholera outbreak.
As of 3 December, there had been nearly 57,000 suspected cases and 98 deaths across Syria since the government of President Bashar al-Assad announced its first official case of cholera in early September.
The outbreak, linked to the consumption of contaminated water from the Euphrates River, combined with low water levels in northern Syria, has also hit neighbouring Lebanon.
While the wave of infections began in northeast Syria and the disease continues to thrive there, it has now spread to all parts of the country, taking a strong hold in rebel-held Idlib – now the country’s second most-affected province, with more than 12,000 suspected cases.
Idlib and other parts of the northwest are home to 4.6 million people, most of whom were forced to flee their homes elsewhere in Syria. At least 1.7 million live in camps; these are often informal settlements with overcrowded conditions, no running water, and open sewage.
While slowing cholera in the very conditions that allow it to thrive may sound like an uphill battle, healthcare staff like 40-year-old Ibrahim Ahmad al-Alawy, who works for the Union of Medical Care and Relief Organisations (UOSSM), a coalition of groups that provide medical care in Syria, are determined to try.
The father of four, who was forced to flee his home in Hama at the start of Syria’s war, lives with his wife and children in an Idlib camp. He studied and worked as a computer engineer, but decided to study nursing after he saw the acute needs in his war-torn community.
Photographer Muhammad al-Hosse spent one day last month with al-Alawy and his team as they went door to door, tent to tent, to spot possible cholera cases, spreading awareness about the disease and helping ordinary people understand what to do to keep themselves safe.
It’s a tough job — the people al-Alawy visits often need a lot more than he can offer — they ask him for food, money, and help with things he simply can’t provide. But he still feels it’s worth it, because of what he can do.
“My role as a health worker is very important. It’s essential for the well-being of the community. I work to raise awareness, change bad habits, inform people about the services we provide, and help them prevent infectious diseases,” he says. “I’m happy when I can help people overcome the difficult circumstances they are living in, at least when it comes to disease prevention.”
Planning and protection
Having started their day at 8am at the UOSSM office in the Idlib town of al-Dana, reviewing their game plan for the day, al-Alawy and his crew of six colleagues set out for a small camp called al-Sanober, home to around 225 families.
They arrive at the informal camp, near the Idlib town of Deir Hassan, at around 9:30am. As team leader, al-Alawy gives the team a pep talk, then hands out latex gloves, masks for protection against COVID-19, and flyers and stickers with information on cholera they plan to place around the camp.
The crew splits up into smaller groups and heads out into the camp, keeping close track of where they have been and who they have spoken to. Throughout the day, al-Alawy uses an app on his tablet to mark off which tents his colleagues have visited, and where no one was home, so they can come back later.
By 10am, a camp resident approaches the team, concerned his children may have cholera. Al-Alawy heads back to their tent and checks on the kids. He determines they don’t have cholera but are likely suffering from a seasonal cold or flu.
Al-Alawy explains to the father, who requested that his name not be published, that cholera and other seasonal infections are easily confused. He also passes on the contact information for a nearby medical centre, and explains how to manage symptoms of cold and flu. In this case, al-Alawy believes the children are sick because it’s cold and their tent has no heating.
“Coal is the cheapest thing for heating at the market right now, and we can’t use coal here in the camp,” the man says. “We would die of suffocation in the tent [if we used coal]. I feel helpless when it comes to this.”
Taking no chances
A camp resident tells al-Alawy that several kids who live in a gathering of tents nearby are showing signs of what sounds like cholera.
In the tents, al-Alawy finds eight sick children, all with high fever and watery diarrhoea. He calls an ambulance, which arrives in about 30 minutes to take the kids to the hospital.
Later, lab tests show the children did not have cholera, but such testing is often not available and al-Alawy prefers to take no chances. He’s all too familiar with how quickly infections can spread, having worked with UOSSM through the COVID-19 pandemic.
In general, al-Alawy says, camp residents are happy to speak with the outreach workers, even about something as sensitive as severe diarrhoea, one of the symptoms of cholera: “People are happy someone cares about them and their well-being.”
At around 11am, the UOSSM crew moves on to a nearby camp called al-Nahda, home to around 1,100 families. As al-Alawy explains cholera prevention measures — hand washing techniques, where and how to properly dispose of garbage, and the importance of clean drinking water — he also fields questions from the residents, all of whom have escaped war and lived through the COVID-19 pandemic.
“Is cholera more dangerous than coronavirus?” one man asks.
Another asks when NGOs will fix their toilets, or bring them clean water. Providing these services is not part of al-Alawy’s job, but he often finds himself connecting with other aid groups when people need help.
‘Don’t risk your life’
Al-Alawy is always on the lookout for good places to post stickers with information about cholera and safe water — plus emergency numbers to call – especially close to water tanks that are used for drinking and washing.
Here he puts explanatory posters on the back of a camp water tank. “Don’t risk your life or your family’s life with bad water,” he tells one man.
In al-Nahda camp, members of the UOSSM crew sit with Salem al-Hamwi and his family, showing a video about how to prevent cholera, and how to spot symptoms.
Al-Hamwi, who is paralysed from the waist down and can’t afford a wheelchair, is thankful for the information about cholera, but says people in the camp will need a lot more than awareness to stop the disease. He complains that the camp’s water tanks pump dirty water. “If cholera spreads here, it will kill us,” he says, noting that the camp has only one toilet for around 10 overcrowded tents.
He also asks for help with food, money for a small shop, and medical help. Without a wheelchair, the only way he can get around the camp is by crawling. Al-Alawy notes down his information for follow-up by UOSSM’s medical staff.
‘I know I have made a contribution’
Al-Alawy and his colleagues head back to the UOSSM office at around 1:45pm, having met with around 15 families, and identified eight potential cholera cases across the two camps. They document their day’s work, noting where they need to return to the next day and which cases need follow-up.
The job can be frustrating, and sometimes dangerous. Often, the healthcare workers have to wade through mud to get to camps that aren’t accessible by road. On some days, they’re dealing with open sewage, or stuck inside leaky tents during a downpour.
But al-Alawy is determined. “Getting to the more remote camps is one of my priorities,” he says. “I go back and forth between these camps, and have reached thousands of people… I have heard their stories and their pain. And I know I have made a contribution.”
The New Humanitarian used transportation provided by UOSSM.
Edited by Annie Slemrod.