Syria Insight: Cholera's deadly shadow hangs over poverty-stricken northeast

Cholera, a disease hoped banished from Syria, has re-emerged among the country's sprawling city-sized camps and neglected towns of the east.

At least 24,000 cases and 80 deaths have been reported in Syria, which the UN has warned is spreading with alarming ferocity and now into neighbouring Lebanon.

Aid agencies have issued a response plan calling for urgent help to tackle the crisis, which in a war-torn country like Syria - ravaged by extreme poverty and hampered by crumbling health services - threatens thousands of lives. 

So far, NGOs are dealing with the outbreak the best way they can - chlorinating water, handing out cleaning products, and spreading awareness of cholera - but say they can only stave off the disease for so long.

"Since the first cholera cases were recorded last August, the disease has torn through Syria's northern and eastern towns and villages"

"The current cholera outbreak is compounded by a lack of access to safe drinking water, increasing need, continued displacement, and limited accessibility of the general population to adequate sanitation and health facilities," said Jennifer Higgins, Syria Policy, Advocacy and Communications Coordinator with International Rescue Committee (IRC).

"Protecting and expanding access to health and humanitarian services should be prioritised to ensure that Syrians achieve the right to health and well-being."

Since the first cholera cases were recorded last August, the disease has torn through Syria's northern and eastern towns and villages, areas lying along the Euphrates River and controlled by either pro-regime or Kurdish forces.

The World Health Organisation (WHO) recorded 13,059 suspected cases of the disease between 25 August and 4 October, while all of Syria’s 14 provinces have now reported a cholera incident.

That number has now increased to over 24,000 suspected cases, highlighting the alarming spread of the disease.

Carriers of cholera - a food and water-borne disease - usually experience acute diarrhoea and dehydration which can be fatal if left untreated and has been the outcome in around one in 200 cases in Syria.

NGOs say that the real figure is likely much higher and that a lack of testing kits means that asymptomatic carriers remain undetected and likely contribute to its spread in their communities.

Polluted waters

The cholera outbreak appears to have originated from the Euphrates River with tankers - usually owned by individuals - shipping contaminated waters to towns and villages amid reports of little to no oversight of this industry by the local Kurdish-led administration.

Avin Sheikhmous, media director at the Ezdina Foundation, said that the water of the Euphrates appears to be a source of the disease but also blamed other factors for its emergence and spread.

"It is known that when water is contaminated, and now, everyone knows that the Euphrates River is polluted, there are vegetables which are watered with that water… so it is likely and very natural that cholera will spread by way of the vegetables and via eating also," Sheikhmous told The New Arab.

The New Arab saw no evidence of allegations made by Sheikhous that Turkish-backed forces directly or indirectly contributed to the outbreak, but NGOs have said drought connected to Ankara's control of upstream waters has partly exacerbated the crisis.

"The humanitarian situation in Syria is worsening. The cholera outbreak is an additional layer for which the humanitarian community needs to find additional funding as we are overstretched already in our response"

Water shortages

The breakdown of the Alouk water station in Al-Hassakeh province from June until October, which provided water to around half a million Syrians, is another factor in cholera's spread. 

At least one NGO has raised issues for the Damascus-based response teams to gain permission for some medicines to reach the self-governed northeast Syrian region but this is being solved.

Sheikhmous claimed the swift response needed to tackle the outbreak has been hampered by alleged resistance of the Syrian regime to divert supplies to the region and WHO compliance.

"[We suffer] from this treatment from the international organisations and the WHO, which should deal with NE Syria in a humanitarian way and on a humanitarian basis, not according to their whims or moods, but unfortunately there has been no assistance from them until today," the journalist claimed.

The WHO rejected the criticism of not providing adequate support to NE Syria.

"In the current cholera outbreak, the WHO has continued working to provide assistance and support to all areas within Syria, including cross-line support in northeast Syria," a WHO spokesperson told The New Arab.

"To date in northeast Syria (NES), more than 2.8 million chlorine tablets used for household level disinfection of water have been disbursed to health actors working across ALL areas of northeast Syria, including those outside of governmental control."

The WHO said that cholera supplies across the world are being depleted due to a global outbreak, which has caused delays.

"The WHO also fully depleted its existing contingency stock of oral rehydration salts (ORS) and IV fluids by distributing them to partners and hospitals operating within areas of governmental and non-governmental control," the spokesperson said.

On Tuesday, a large shipment of ORS sachets and cholera kits arrived in Qamishli, which will be distributed to public hospitals and NGOs in northeast Syria once permissions are received, the WHO said.

The WHO said it has continuously delivered cross-line support to non-governmental areas of northeast Syria but has suffered from significant funding cuts over the past 18 months with more expected.

"The entirety of the response - including cross-line support in northeast Syria - will face increasing needs and response gaps unless additional resources can be mobilised," the WHO said.

The comments came before an AP investigation alleged that the WHO in Damascus under Dr Akjemal Magtymova had focused Covid-19 aid on regime-controlled territories and neglected other areas of Syria.

NGOs have also voiced concerns about the struggles in obtaining hygiene kits, medicine, and testing equipment needed to adequately tackle the crisis.

"The humanitarian situation in Syria is worsening. The cholera outbreak is an additional layer for which the humanitarian community needs to find additional funding as we are overstretched already in our response," Bahia Zrikem, Syria Response at the Norwegian Refugee Council, told The New Arab.

"We are looking now at a response with increased needs and a stable funding landscape that will probably reduce in the coming years.

"We, the humanitarian actors and donors, are not enough anymore to support Syrian people… a cholera epidemic in Syria would be a humanitarian catastrophe and humanitarian actors will do all they can to prevent that from occurring."

"If cholera spread in Al-Hol or any other camp then the situation would be very difficult to control"

Threats

Although the outbreak is still not at the epidemic stage, Syria's existing humanitarian issues mean that the cholera outbreak could overwhelm medical workers.

Among the areas of concern is Al-Hol camp, home to 56,000 people, 75 percent of them children, where aid workers are desperately trying to prevent an outbreak of cholera. 

"Children there are trapped in a very dire and insecure situation with very little access to any durable solutions for the future," said Zrikem.

NGOs have taken advantage of Al-Hol's isolation to ensure trucks deliver only safe, chlorinated water to the camp, and have provided awareness of the disease to residents and handed out hygiene kits.

Yet with tens of thousands of children trapped in Al-Hol and other camps, an outbreak of the disease would be catastrophic.

"If cholera spread in Al-Hol or any other camp then the situation would be very difficult to control," said Zrikem.

Paul McLoughlin is a senior news editor at The New Arab. 

Follow him on Twitter: @PaullMcLoughlin