It had been difficult, but by January, doctors across north-west Syria believed they had almost beaten a major outbreak of cholera. An estimated 50,000 infections and almost 100 deaths had been recorded in Idlib and neighbouring Aleppo governorates between August and December. The outbreak had even spilled over into neighbouring Lebanon, the first case in the country since 1993, resulting in at least one death. But a planned vaccination campaign was meant to mark the end of the surge in cases.
Then two earthquakes struck the region in early February, compounding the worsening living conditions, destroying infrastructure and further displacing many people who had already fled to Idlib to escape fighting elsewhere. The earthquakes killed more than 4,000 people across north-west Syria, rupturing underground piping and damaging hospitals. Floods and windstorms destroyed thousands of homes in the weeks after the shocks.
In fragile tent camps spread over the rocky hills, almost 2 million people internally displaced by war were already trying to survive in makeshift homes in a small area of rebel-controlled land. Many people didn’t have access to basic sanitation or a reliable water source, making them susceptible to disease spread by contaminated food and water.
The devastation of the earthquakes made a resurgence in cholera inevitable. By early April, more than 13,000 cases and at least 23 confirmed deaths had been recorded in the region.
“We did our best to contain the outbreak,” says health official Hussein Bazaar, bowing his head in the corridors of the Bab al-Hawa hospital, on the border with Turkey. A supply of cholera vaccines arrived in Idlib 10 days before the earthquakes, he says. “The cholera outbreak got cast aside as bigger things happened, given our limited capacity.”
“I’m worried, as the earthquakes affected the water supply, and basic infrastructure was destroyed,” says Dr Wajih al-Karrat, as he moves between beds in a makeshift hospital that was once a school, in the town of Haram. Around him, children wail in their beds, the lack of basic supplies evident on the shelves above them. Chipped paint covers the walls as nurses scrub the corridors.
The resurgence of cholera across Syria, one of 22 countries that have reported cases over the past year, feeds on long-term infrastructure problems that plague the north of the country, as well as disrupted aid supplies.
Mohammed al-Jasem, health coordinator for the International Rescue Committee in Syria, says that the earthquakes made it even more difficult to treat cholera, given the damage to healthcare infrastructure and movement of displaced populations, as well as the risk of attacks by the government in Damascus. A lack of funds continues to hamper progress. Medics who have entered northern Syria, using aid corridors reopened after the earthquakes, have spoken of serious delays in transporting vital goods across the border.
“As a result of the earthquake, surveillance activities [for cholera] were temporarily put on hold, some cholera treatment centres were used as trauma centres and others as shelters for the displaced communities,” he says. “The conditions at reception centres are characterised by overcrowding, water, sanitation and hygiene challenges. Such a situation creates a suitable environment for the spread of communicable disease outbreaks and threatens achievements made so far to control cholera.”
An oral cholera vaccination campaign in the weeks before the start of Ramadan reached 1.7 million people across northern Syria, according to the UN children’s fund Unicef. A second cholera vaccination campaign is due to start at the end of the Islamic holy month, targeting a further 1.2 million people.
Despite the vaccination campaign, Ammar Ammar, a Unicef spokesperson, says the conditions in temporary accommodation could still aid the spread of disease. “Despite the fact that the number of displaced people in reception centres is decreasing, the risk of an increase in waterborne diseases such as cholera remains extremely high due to overcrowding, extensive damage to water and sanitation infrastructure, and damage and disruption to cholera treatment infrastructures,” he says.
Aid groups say their mandate in Syria leaves them struggling to tackle the underlying causes of cholera. Ensuring clean water supplies or major infrastructure changes are needed to prevent the disease becoming endemic, says Ammar.
