Northern Syria’s cholera outbreak spreads, reaches Idlib displacement camps

AMMAN — Amid a growing cholera outbreak across northern Syria, Idlib recorded its first three cases in the Kafr Lusin displacement camps in the province’s north, the opposition Idlib Health Directorate said on Monday. With the newly announced cases, the outbreak has now reached all areas of control in northern Syria. 

Collectively, hundreds of infections and dozens of deaths have been recorded in areas controlled by the Syrian Democratic Forces (SDF), regime and Turkish-backed opposition Syrian National Army (SNA). 

As of September 25, the Early Warning Program of the Assistance Coordination Unit (ACU), a Syrian non-governmental organization, recorded 4,100 cases of cholera in northeastern and northwestern Syria. Most infections were in SDF-controlled areas, which had 4,017 cases, including 17 deaths. The Damascus Ministry of Health has recorded 338 cases of cholera, 230 of which were in Aleppo governorate, as well as 29 deaths, 25 of which were in Aleppo. 

Cholera is an acute bacterial disease—mainly caused by ingesting food or water contaminated with Vibrio cholerae bacteria—that causes diarrhea and dehydration, which in severe cases can be fatal. 

After cholera broke out in Syria’s eastern Deir e-Zor province, the area with the most cases in the country, earlier this month, Emad al-Ahmad, a pharmacist from western Deir e-Zor, joined a group of young volunteers “to educate people about the danger of the epidemic, and how to confront it to break the chain of infection,” he told Syria Direct. With Syria’s health infrastructure fragile after more than a decade of war, raising awareness is key, he stressed.

Causes of the outbreak

On September 21, the Autonomous Administration in North and East Syria (AANES) held a press conference in Qamishli on cholera infections in its areas of influence. The joint head of the AANES health department, Jwan Mustafa, said “analyses confirmed the presence of Vibrio cholerae responsible for the disease in the Euphrates River.” 

Receding Euphrates River waters were the cause, he said, “turning it into swamps in many areas, as well as the contamination of vegetables irrigated with river water.” 

Dr. Hassan Amin, a member of the Kurdish Red Crescent, told Syria Direct “the receding waters of the Euphrates and other rivers, such as the Jaqjaq and Khabur Rivers in Hasakah province, led to the formation of swamps. These became places where filth collects, polluting the environment and water.”

Repeated cuts of water from the Alouk pumping station—which feeds parts of Hasakah province—located in SNA-held Ras al-Ayn, have pushed “many people to drink non-potable water,” Amin said. Crops are also watered with “contaminated water from sewage in Nusaybin,” a Turkish city across the border from Qamishli, he added. 

A large number of sewage channels flow into the Euphrates River in Deir e-Zor, and “most water [pumping] and purification stations have stopped working due to poor water lines and reliance on informal wells or water that is trucked in,” Amin said. 

Dr. Muhammad Saleh, an official with the ACU’s Early Warning Program, attributed northern Syria’s cholera outbreak to “shared water sources” across the area’s various lines of control.

A fragile environment

The current cholera outbreak is the first in Syria since 2011, and the first since the disease spread in Raqqa and Deir e-Zor in 2008 and 2009. Deir e-Zor pharmacist al-Ahmad accompanied a cholera patient at one of his region’s hospitals during those outbreaks, and remembers “the situation was catastrophic, the hospitals were packed.” 

But the current outbreak is particularly worrying because, after a decade of upheaval and the COVID-19 pandemic, “the medical sector is not ready to face an epidemic,” al-Ahmad said. 

He worries cholera could be a fatal blow to Syria’s health sector, which “had just emerged from the COVID-19 crisis, and the region is still witnessing daily deaths” from that disease. Many cholera cases do not lead to severe symptoms, but with an already weak health infrastructure, “what will the health situation be in the face of this new epidemic?” al-Ahmad wondered. 

In response to the outbreak, local AANES authorities have worked to sterilize informal water sources and provide supplies to hospitals. Al-Ahmad criticized the response as weak so far. Despite a high number of cases in Deir e-Zor, the AANES health department announced it provided al-Kasra Hospital, in the west of the province, with “14 beds, 18 serum holders and 20 medical curtains for cholera patients.” 

So far, the number of recorded cholera infections in northwestern Syria are far below the number in northeastern Syria. But the outbreak’s spread to an area inhabited by around four million people, half of whom are displaced, has sparked fears of a humanitarian disaster. Especially worrying is the area’s “poor infrastructure, scarce potable water and large population centers in the camps,” Early Warning Program official Saleh said. These are “predisposing factors for spread,” he added.  

As of today, “there are no dedicated medical centers for cholera patients” in the northwest, Saleh said. “Work is underway to prepare a dedicated medical infrastructure.” 

In the northeast, the Kurdish Red Crescent is organizing “awareness campaigns, conducting field visits to schools and educating teachers, who play a role in educating their students,” Amin said. The organization is also “sterilizing water tanks at schools and official departments.” 

Amin stressed the need for coordination between the AANES health department, Doctors Without Borders (MSF) and the World Health Organization (WHO) to respond to the outbreak. But as things currently stand, “awareness is the most important weapon to stop the epidemic,” he said. “Personal hygiene, drinking clean water or boiling water before drinking it, washing vegetables and sterilizing water tanks with chlorine are measures that limit the spread of cholera.” 

During recent field visits in Deir e-Zor, pharmacist al-Ahmad has noticed “people’s responsiveness in Deir e-Zor to the awareness teams, and they started buying water purification tablets from the pharmacies.”

His worry, however, is that Syrians overall no longer care about risks and epidemics, as “no tragedy shocks us anymore.” 

This report was originally published in Arabic and translated into English by Mateo Nelson.