Cases of sandfly-borne skin disease surge in rebel-held Idlib as international funding dries up and sanitation services falter

AMMAN: Sayyed Qasim and his family had been in the Idlib town of Aramanaz for about a week when they felt the irritating bites, which they quickly traced to a flurry of small black flies that had entered their home.

Having heard about a pandemic sweeping the city they fled to in mid-April to escape fighting in their native Maarat a-Numan, Qasim and his wife headed straight to the municipal health center. The doctor there immediately recognized their description of the biting insects as sandflies, the main carriers of the flesh-eating leishmaniasis parasite. He prescribed them a round of preventative medicine, keen to avoid new victims amidst an onslaught of leishmaniasis that is exploding in northern Syria.

Across medical clinics in rebel-held Idlib province, doctors have noticed a startling trend since the beginning of the year. New cases of leishmaniasis are exploding at rates approximately double those witnessed last year, with local specialists citing 6,273 confirmed cases province-wide in just the first four months of 2018. That puts 2018 on track to more than double the numbers recorded in 2015, the last year for which information is publicly available.

Ground zero in the leishmaniasis outbreak is the small border town of Armanaz. There, the local clinic has witnessed a more than six-fold increase in cases since last year, according to Dr. Saleh Haj Taher, president of the Armanaz health center. He says the local clinic received more than 250 new cases in the month of April alone, compared to around 40 infections for all of 2017.

“The number of cases here is just extraordinary,” Taher tells Syria Direct.

The small bloodsucking sandfly, about a quarter the size of a mosquito, lays its eggs in piles of trash and organic waste. Female flies carry the disease-causing leishmania parasite, infecting humans and other mammals through their bite. While symptoms vary from victim to victim, the first signs are generally small bumps that erupt in the weeks following infection, which then swell and open up into raw, disfiguring lesions.

Displaced families at a mobile medical clinic in Idlib 0n March 29. Photo by Zein Al Refai/AFP.

While not lethal, these open welts can lead to social stigma and can only be cured with repeated medical injections, usually in the form of a highly toxic antimonial treatment that can cause debilitating side effects such as severe nausea and weight loss. The cost of treatment also tends to run high compared to treatment of other tropical, vector-borne diseases. A typical treatment regime for one affected individual can cost $25, with multiple injections needed to kill the parasite.

Alvaro Acosta–Serrano from the Liverpool School of Tropical Medicine has been studying and tracking the spread of leishmaniasis in Syria for years. His research puts the total number of leishmaniasis cases in Idlib province alone last year at 75,000, though he says this could be an underestimate when accounting for those unable to reach clinics and seek treatment.

“It is impossible to know how many people aren’t making it to clinics,” he says.

Taher from the Armanaz clinic contends that the recent explosion of leishmania there is no coincidence, but rather the result of an underfunded local government and deteriorating living conditions.

Under the strain of bombardment, an influx of displaced people and evaporating municipal funds, sanitation infrastructure in Armanaz has begun to falter. Residents say open sewage flows through the streets and garbage piles up for weeks at a time along the avenues without being collected. These deteriorating hygienic conditions have birthed a perfect environment for a spectacular growth in the sandfly population.

Local Council chairperson Hassan Sardani does not deny that the pandemic is linked to failing sanitation services and shattered infrastructure, but he says that the local government can do little about it. Shattered infrastructure must be rebuilt, municipal funds have run dry and international funding for preventative measures such as protective nets and spraying operations has dried up.

While some sandfly-preventing pesticides are being dispersed across Armanaz, their effectiveness is limited, he says.

“The amount is small and insufficient,” says Sardani. “Those who go out to spray the pesticides are volunteers. We are not able to solve this on our own as a local council, and we appeal to all organizations working in the medical and health field to help us.”

Further compounding the problem of poor sanitation, a wave of displaced people has arrived in Armanaz during recent months. According to a February 2018 survey, 43 percent of the city’s population is currently composed of displaced families from other parts of Syria.

Leishmaniasis is notorious for targeting and following refugee communities wherever it appears—which has helped to make the disease in many ways synonymous with the Syrian crisis.

Acosta-Serrano says that displacement and movement of peoples is one of the strongest predictors of leishmaniasis outbreaks. The geographic position of Idlib province, and Armanaz in particular as a gateway to Turkey, makes northwestern Syria particularly susceptible to emerging pandemics.

Wastewater gathers in the northern Syria town of Kafr Naha in 2017. Photo courtesy of SMART News Agency.

“Before the war, Idlib counted for about 20 percent of total cases [of leishmaniasis] in Syria per year,” Acosta-Serrano says. “It is a place where many people have [historically] come in and out because of the proximity with Turkey.”

Prevalent in the Middle East for centuries, regional leishmaniasis has gone by many names, including the rose of Jericho and the Aleppo boil. Outbreaks have been recorded in Syria, most famously in Idlib and Aleppo provinces, since at least 1745.

Thousands of cases were recorded annually in the country even prior to the outbreak of armed conflict in 2012, but numbers exploded soon after as preventative pesticide regimes faltered and sanitation services were wiped out in many regions alongside the general breakdown in law and order. New annual cases spiked at the onset of the war, quadrupling from 3,820 in 2012 to 12,327 in 2013. The pandemic grew and thousands of disfigured victims began pouring into neighboring countries as refugees, attracting global attention.

Acosta-Serrano says that one major factor in the rise and fall of leishmaniasis infection rates is the level of funding for prevention efforts from international organizations. As the generosity of donors has waned in recent years, so too have serious measures to combat the spread of leishmaniasis.

The Mentor Initiative, which spearheads projects around the world to treat and prevent tropical diseases, has been largely coordinating the effort to combat leishmania throughout Syria. Program director Richard Allen says that the organization has trained 2,000 health professionals across the country to administer the sensitive injections that treat the lesions, and founded 40 mobile clinics.

On the preventative side, the organization has distributed mesh nets and reintroduced pesticide regimes throughout the country. They credit these efforts with reducing new infections across Syria, with the greatest drop occurring in Idlib between 2013 and 2015.

“We have very clear evidence in Idlib,” says Allen. “We were able to halve all the leishmaniasis transmissions there.”

However, severe financial troubles arrived in 2016 as donors closed their pocket books and the WHO broadly reduced funding for leishmaniasis initiatives in the war-torn nation. While the Mentor Initiative was able to keep supplies of medicine flowing to Idlib province, it has been forced to dramatically curtail preventative measures there.

Allen says the rise in cases around Idlib comes as no surprise and heralds a return to the higher infection rates that clinics were reporting before they set up their preventative programs.

“It’s a classic scenario,” says Allen. “You can control a disease if you keep the investment there, but if you stop—in a warzone—you have a constant increasing trend and the disease recovers.”

With additional reporting by Alice Al-Maleh.

Bahira al-Zarier

Bahira is from Damascus. She studied business and marketing before moving to Jordan in 2013. She did volunteer work in support of many refugee organizations before joining Syria Direct.

Barrett Limoges

Barrett Limoges is an investigative journalist who has reported from across the MENA region, his work appearing previously in Al Jazeera, Middle East Eye, PBS Newshour, Al-Monitor, Huffington Post and other publications. He studied journalism at the University of King's College and is currently pursuing a MA in Political Science at the American University of Beirut.