2 Aug 2022

Syria’s cholera outbreak: Impacts and implications for the conflict and region

Alexander Langlois

Syria is facing an unprecedented cholera outbreak heading into the winter months, against the backdrop of the worst humanitarian metrics witnessed in the country during its nearly 12-year war. With cases rapidly increasing within one of the most difficult humanitarian contexts in the world – both in terms of access and funding – the international community is faced with a deeply complicated scenario that requires a rapid response. The outbreak carries health implications for the region as well, evidenced by the appearance of the disease in neighboring Lebanon and Iraq, suggesting world leaders and global institutions will be hard-pressed to raise awareness and funds as quickly as possible to stimy the disease’s regional spread. Additionally, for Syria, world leaders must consider the upcoming re-authorization vote at the United Nations Security Council (UNSC) on the cross-border aid mechanism that supports millions of Syrians in non-regime lands. Understanding what the international community is already doing to mitigate the risks of Syria’s cholera outbreak, the challenges to those efforts, and what the future holds are critical in this regard.

Syria’s cholera outbreak and the international humanitarian response

Experts suspect the cholera outbreak in Syria began in late August 2022.[1] The Syrian Ministry of Health declared an outbreak on September 10, following at least 8 recorded deaths and 936 cases of severe acute watery diarrhea (AWD). At the time, most cases were reported in Aleppo and Deir Ezzor governorates, although other cases appeared in the Raqqa, Hasakah, Hama, and Latakia governorates.[2] Total suspected cases have risen to at least 35,569 as of November 9, 2022, including 92 associated deaths at a case fatality rate of 0.30 percent.[3] Roughly 34 percent of all stool sample tests (391 of 998) have tested positive for Vibrio Cholera as of November 1.[4]

Cholera cases are now being reported in all 14 Syrian governorates, with the most widespread outbreak in Deir Ezzor – roughly 15,885 suspected cases constituting nearly 48 percent of all cases in Syria. Followed closely behind Deir Ezzor is Raqqa (8,420 cases; 24 percent), Aleppo (35,996 cases; 16.9 percent), Idlib (3,305 cases; nearly 9 percent), and Hasakeh (1,501 cases; 4.2 percent).

World Health Organization (WHO) officials based in Damascus confirmed to this author the root causes underlying the outbreak: “Climatic-induced and human-caused shocks affecting natural resources, particularly water, continue to intensify and exacerbate the humanitarian situation. Insufficient and poorly distributed rainfall, severe drought conditions combined with low water levels in the Euphrates River, a regular and sustained cut-off of Alouk water station, and damaged water infrastructure have not only reduced access to safe water for drinking and domestic use for millions of Syrians but also agricultural purposes,” noted one official in an anonymous interview.[5] The Alouk water station shutdowns are particularly concerning as it provides water for roughly 460,000 Syrians downstream in northeast Syria (NES). Many experts and locals believe that Turkey hopes to destabilize Kurdish lands by harming water security in such ways – a charge Ankara denies.[6]

According to the WHO, the cause of the outbreak stems from individuals consuming infected water or food from the Euphrates River. Sewage and untreated human waste are regularly dumped into the river, causing the disease to flourish.[7] Untreated water is a result of “nearly two-thirds of water treatment plants, half of all pumping stations, and one-third of water towers [being] damaged because of the conflict. Water networks are unable to provide full water quantities to the population due to the lack of a stable power supply, the high cost of diesel to operate the power generating systems and fixed budgets, and the prolonged drought,” said the WHO official. Unwashed food is also severely impacted by the issues with the river, leading the regime to order all potentially contaminated food to be discarded.

Unfortunately, due to these factors and the general widespread destruction of water treatment infrastructure and other water facilities, many individuals caught the disease by turning to private water companies with poor safety practices. These companies fill water bottles and other containers directly from the Euphrates without proper treatment and safety measures, meaning roughly half of Syrians are forced to buy contaminated water out of necessity from an unsafe source due to a lack of alternative options, according to the WHO official. Given that nearly 60 percent of Deir Ezzor residents rely on such alternative options for water, it is unsurprising that the governorate is experiencing the most cases.[8]

The international response to these shortcomings has been swift. The WHO released its AWD/Cholera Response Plan on September 29, following consultations with the Syrian government, international organizations, humanitarian organizations, and other officials in opposition-held areas, highlighting funding requirements and other necessities in the coming months to properly address the disease outbreak. The plan outlines roughly USD $35 million for all necessary materials and services, excluding an oral cholera vaccine.[9] It also outlines multiple objectives, centralizing disease surveillance and detection, treatment for suspected cholera patience, vaccination campaigns, and drastically expanded water, sanitation, and hygiene (WASH) programming.

Additional emergency funding is helping to get operations off the ground quickly – not limited to recent flexible funding from the Norwegian government to the WHO – allowing the international organization to spend on urgent needs as they arise.[10] This enabled the WHO to procure extensive medical supplies in the first days of the outbreak, including cholera test kits, oral rehydration solutions, rapid diagnostic tests, and medical supplies for intravenous (IV) rehydration treatment, in addition to chlorine for water purification. The funding and supplies will allow local health officials and other organizations to provide treatment for 2,000 severe cholera cases and around 190,000 cases of AWD, said the WHO official.

Yet, even with international organizations pressing to prevent the spread of cholera within Syria, severe limitations remain. United Nations officials have emphasized a drastically growing need for resources within Syria and a serious funding gap for most of 2022, highlighted by the European Union-hosted Brussels VI Conference in early May, which was only able to raise USD $6.7 billion.[11] The United Nations had originally sought USD $10.5 billion for 2022 alone. Since then, the overall humanitarian response is still only 26.6 percent funded according to the UN Office for the Coordination of Humanitarian Affairs (OCHA).[12] Such a massive gap comes as 14.6 million Syrians out of a total estimated population of 21.7 million people await aid ahead of the winter months – a period UN officials warn will mark the worst winter of the conflict.[13] Roughly 90 percent of Syrians live below the poverty line and 80 percent are food insecure amongst a population with 7 million internally displaced persons (IDPs) and at least 6 million reliant on World Food Program aid to feed their families.[14] Given that over 5 million people in Syria rely on the Euphrates for water, which is now deemed unsafe, the country cannot afford the cholera outbreak today, and especially not heading into the winter, given that every other major aid program is severely underfunded.[15]

Regional implications

Syria’s cholera outbreak and the difficulties that have arisen – and will continue to arise – in mitigating its spread, carry deep regional implications as well. Lebanon is already faced with 1,400 suspected cases of cholera that have resulted in 17 deaths since the first case was confirmed on October 5.[16] Most of these cases have arisen in informal camps developed by Syrian refugees across the small eastern Mediterranean country. Within this context, Syrian refugees in Lebanon have nothing – from health services and reliable shelter to basic sanitation necessities like running or clean water. Unfortunately, it appears that the same dynamics that caused the outbreak in Syria were also responsible for the outbreak in Lebanon, although it is still unclear whether the disease managed to cross the border.

Iraq, which has suffered from severe cholera outbreaks for decades, is experiencing similar issues as Lebanon and Syria. The country faced upwards of 738 confirmed cholera cases in early August, concentrated in urban centers like Baghdad and Kirkuk.[17] The WHO has indicated that much of this stems from a lack of social development – particularly health services but also basic water treatment infrastructure. Fortunately, given the history of cholera outbreaks in the country, the WHO and other international organizations are relatively better equipped to address the outbreak.

In each of these countries, a common trend of conflict, limited development, and climate change present themselves as the driving factors behind the outbreak of various diseases – including, and particularly, cholera. The region remains one of the most water-deprived in the world, worsening such dynamics amidst substantial and growing populations. UN agencies have warned of such implications for years, but a lack of proper funding and the fluctuating intensity of conflict regularly stimies such efforts. This is only worsened by a global shortage of critical supplies to prevent and treat cholera, not limited to the oral cholera vaccines, according to the WHO official.

Additionally, a reaction-based approach that is humanitarian in nature often fails to address the root causes of the problem in ways that development-based approaches, coupled with strong political engagement, may help to address. Worse, geopolitical interests at all levels of governance and diplomacy often take precedence over long-term resolutions of issues, sustaining an untenable status quo for the region. One need only look at the political gridlock in Lebanon, Syria, and Iraq, as well as international realpolitik from world and regional powers, to observe this reality in real time.

Suhail al-Ghazi, a Syrian researcher, noted in an interview a wide range of risks stemming from Syria’s cholera outbreak, explaining that “the health sector in neighboring countries like Lebanon and Iraq may not be able to handle another crisis. This and the possibility of some countries closing their borders will wear down the trade and the economy in Syria just like the early year of the COVID-19 outbreak. And the outbreak could also cause a further pretext for some political parties to attack Syrian refugees in neighboring countries and increase the pressure on forced deportation.”[18] Indeed, crisis not only feeds other national and sub-national issues, such as disease outbreak, but also carries follow-on impacts that further destabilize countries and put people at risk in the region.

Geopolitical issues

The geopolitical dynamics within the region – particularly in Syria – further harm efforts to address the conflict and present a worst-case scenario in the coming months with respect to the humanitarian response. Central to this dynamic is Syria’s cross-border aid mechanism, which faces another re-authorization vote at the UNSC in January 2023.[19] The mechanism, which has been gradually whittled away by Russia’s veto in recent years, still provides essential aid to millions of Syrians in northwest Syria (NWS) via the al-Bab crossing between Turkey and Syria. It is the only realistic mechanism for aid in this area given Syrian President Bashar al-Assad’s intransigent politicization of aid to opposition areas when coordinated out of Damascus. Indeed, crossline aid – humanitarian aid operations ran through the internationally recognized government’s capital and across conflict lines – rarely reached opposition areas in the past as evidenced by numerous humanitarian and human rights organizations.[20]

Against this backdrop, it is highly likely that Moscow intends to veto any cross-border re-authorization in Syria, or severely harm its legitimacy vis-a-vis crossline aid, out of a desire to garner more concessions on the Syria file. This is evidenced by years of vetoes and drastically worsened Russo-West relations due to Russia’s aggression in Ukraine. Moscow can use the worsening humanitarian situation, undergirded by cholera, to force the West’s hand on crossline operations or other strategic objectives, given that they have regularly given concessions to the pro-Assad camp in the name of humanitarian objectives in the past. Further, even if a re-authorization does occur because of concessions, another 6-month window for the mechanism is likely. This does not offer humanitarian organizations enough time to develop proper plans and certainly plays a role in the worsening humanitarian metrics today. Adding to difficulties is the issue of sanctions on the Assad regime – how will humanitarian organizations respond to increased crossline operations facilitated by Damascus-based organizations if the sector is historically risk-averse to sanctions?

“The proposed mechanism to make the response crossline, rather than cross-border, is not feasible since the Syrian Regime and many of its related staff and companies are sanctioned. [This is] besides the fact that the Syrian regime considers the opposition areas as enemies and [has] targeted areas including the civilians under the excuse that those civilians are the incubator for terrorism,” notes Wasim Alhaj, a Syrian activist and Chairman of GLOCA, a charitable foundation in NWS.[21] “The cross-border aid is very critical since it is the artery of life for NWS in terms of humanitarian aid and commercial activities,” he adds.

Indeed, as was the case with COVID-19 in NES, which lost its cross-border access at the al-Yarubiyah border crossing with Iraq in January 2020, access to basic medical supplies will likely become critically impaired in NWS should the al-Bab crossing close.[22] In NES, hospitals struggled to access basic medical supplies like oxygen for patients – an outcome that could present itself in NWS at the least opportune time given the outbreak.

Policy recommendations and implications

Ultimately, policymakers at all levels must consider the threats cholera presents to the region, as well as to individual states and vulnerable populations – including, and particularly, Syria and the Syrian refugees in Lebanon. This involves regional, national, and sub-national response plans that address basic service needs to both detect, treat, and prevent the spread of the disease.

“There should be more aid to the health sector in NW and NE Syria, and [there is a] critical need to renew the cross-border aid resolution, notes al-Ghazi.[23] “[Leaders] should also push the international community and the UN to revise the work of the UN organizations in regime-held areas to ensure less corruption and better response for the people in need.” Alhaj largely agrees with respect to non-regime areas, adding that “the most critical thing is maintaining the cross-border mechanism.”[24] Indeed, the cross-border mechanism presents the most effective approach to dealing with the laundry list of humanitarian issues present in Syria – including cholera. As witnessed during the COVID-19 pandemic, non-regime areas without a functional cross-border mechanism suffered immensely from supply shortages. If cross-border aid ends for the millions of Syrians in NWS, a similar or worse scenario will likely occur in the area as it did in AANES-controlled NES during the pandemic.

Efforts to increase emergency and longer-term funding are also wise. Major funding shortages across all humanitarian response efforts in the country today helped lead to the outbreak, amongst other persistent issues like corruption and war. Both root causes and immediate humanitarian needs can be met with quick and flexible funding for non-regime areas, understanding that funding for regime areas must become more accountable following major corruption scandals unearthed in late October.[25] This is not to suggest funding should be cut or even severely delayed in these areas – rather, a serious conversation about effective procurement processes is necessary to ensure aid reaches the average Syrian citizen more effectively and without enriching war criminals. Regardless, Alhaj points to some critical core issues behind the cholera outbreak that must be addressed with long-term solutions in places like NWS, and calls for a “focus on recovering the infrastructure, especially sewage systems and WASH facilities; serious prioritization of maintaining the dams and water pumps; and improving the irrigation networks to be depended on clean water rather than sewage water.”[26] Indeed, such solutions can and should take widespread precedence nationally and responsibly.

Increased funding also helps with near-term risks. Alhaj notes this, explaining that “the decisive factor in cholera outbreak is controlling the sources of water, where chlorination of drinking water in tanks and wells on which the camps inhabitants rely is an essential part of the response. This intervention took place as early as possible in northern Syria that helped a lot in preventing the spreading of cholera into camps.”[27] Alhaj does not support a review of sanctions, however, to address underlying issues.

Ultimately, ending the war and introducing increased levels of economic activity will be crucial to preventing future outbreaks. This involves rebuilding agriculture, health, and water infrastructure and services – which are impacted due to sectors either being heavily sanctioned (i.e., construction) or hindered by international financial institution de-risking.[28] Remittances are one core issue here as Syrians would benefit from access to such services to purchase safer food or water during the outbreak, but such concerns also extend into imports of crucial items like agricultural equipment or medicine – crucial items either directly blocked by sanctions (i.e., agricultural products) or indirectly stymied due to sanctions risk aversion.[29] As the WHO official notes, “sanctions impact both the cholera outbreak and response,” blocking “importation of spare parts” for water pumps. “Limited funding and restrictions/redlines on the extent of rehabilitation mean health facilities, electrical grids, and water networks are rarely able to regain their full purpose nor able to accommodate projected growth.”[30]

Ultimately, preventing recurring problems like cholera requires a full review of the policies at play, just as the US re-assessed the sanctions impact on NES earlier this year, releasing a waiver.[31] This takes a balanced approach and does not need to empower war criminals in Syria. Rather, it requires increased engagement and oversight on Syria and true coordination – behind humanitarian principles – to prevent unexpected harm to civilians.

References

[1] Solidarités International, “Syria: Emergency Response to Contain the Cholera Outbreak,” October 3, 2022, http://bitly.ws/wvon.

[2] United Nations, United Nations Resident and Humanitarian Coordinator in Syria, Imran Riza, Statement on the Outbreak of Cholera in Syria, Office for the Coordination of Humanitarian Affairs, September 12, 2022, http://bitly.ws/wvpM.

[3] UNICEF, Whole of Syria: Cholera Situation Report, November 9, 2022, http://bitly.ws/wGVe.

[4] World Health Organization, Whole of Syria: Cholera Outbreak Situation Report No. 5, November 1, 2022, http://bitly.ws/wvq6.

[5] Not-for-attribution interview with a Damascus-based WHO official on November 8, 2022.

[6] Khaled al-Khateb, “Turkish-backed Syrian Group Cuts Off Water to Hasakah,” Al-Monitor, October 8, 2022, http://bitly.ws/wvqe.

[7] Sasha Fahme, “War and the Weaponisation of Water Are Driving Cholera Epidemics,” Alaraby, October 7, 2022, https://cutt.ly/4MyStKk.

[8] United Nations Children’s Fund (UNICEF), “Bolstering Efforts to Fight Cholera in Deir-ez-Zor,” October 18, 2022, http://bitly.ws/wvsr.

[9] World Health Organization, Syria AWD/Cholera Response Plan, September 2022, http://bitly.ws/wvsx.

[10] World Health Organization, “Norway Lends First-hand Support to WHO in Response to the Cholera Outbreak in Syria,” Regional Office for the Mediterranean, October 4, 2022, http://bitly.ws/wvsT.

[11] European Union External Action, “Brussels VI Conference: ‘Supporting the Future of Syria and the Region’,” http://bitly.ws/wvta.

[12] UN Office for the Coordination of Humanitarian Affairs (OCHA), Humanitarian Update Syrian Arabi Republic – Issue 4 | September 2022, November 1, 2022, http://bitly.ws/wvtw.

[13] United Nations, “Political Solution Still the Only Path to Peace in Syria: UN Special Envoy,” UN News, October 25, 2022, http://bitly.ws/wvtG.

[14] Lina Alqassab and Hussam Alsalah, “Displacement, Poverty and Rising Prices: How One Family in Syria Bears the Burden of 11 Years of Conflict,” World Food Programme, March 15, 2022, http://bitly.ws/wvtP.

[15] Human Rights Watch, “Syria: Parties to Conflict Aggravate Cholera Epidemic,” November 7, 2022, http://bitly.ws/wvtU.

[16] World Health Organization, “WHO Warns of Deadly Cholera Outbreak in Lebanon as Cases Increase,” Regional Office for the Mediterranean, October 31, 2022, http://bitly.ws/wvu8.

[17] Relief Web, “Iraq: Cholera Outbreak – Jun 2022,” http://bitly.ws/wvuv.

[18] Interview with Suhail al-Ghazi on November 7, 2022.

[19] Oxfam, “Oxfam Response to the UN Security Council’s Vote on Continuing Cross-border Aid into Syria,” July 12, 2022, http://bitly.ws/wvuD.

[20] Louis Charbonneau, “The UN Security Council Should Renew Cross-Border Aid for Syrians,” Human Rights Watch, June 30, 2022, http://bitly.ws/wvuP.

[21] Interview with Wasim Alhaj on November 4, 2022.

[22] United Nations Security Council, “Resolution 2504 (2020),” January 10, 2022, http://bitly.ws/wvv5.

[23] Interview with Suhail al-Ghazi on November 7, 2022.

[24] Interview with Wasim Alhaj on November 4, 2022.

[25] The Syrian Legal Development Programme and the Observatory of Political and Economic Networks, UN Procurement Contracts in Syria: A ‘few’ Bad Apples? (2022), http://bitly.ws/wvvu.

[26] Interview with Wasim Alhaj on November 4, 2022.

[27] Ibid.

[28] Mohammad Kanfash, “Sanctions and Food Insecurity in Syria,” World Peace Foundation, July 6, 2022, http://bitly.ws/wvvJ.

[29] Dahlia Nehme, “RPT-Syria Sanctions Indirectly Hit Children’s Cancer Treatment,” Reuters, March 16, 2017, http://bitly.ws/wvwp.

[30] Not-for-attribution interview with a Damascus-based WHO official on November 8, 2022.

[31] U.S. Department of the Treasury, “Issuance of Syria General License 22; Publication of New and Amended Syria Frequently Asked Questions,” May 12, 2022, http://bitly.ws/wvwH.

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