Northeastern Syria is witnessing a surge in cholera infections and deaths. Syria’s vulnerable infrastructure and poor resources, weakened over years of war, are affecting its ability to contain the disease, which is becoming a serious threat to Syria and neighboring countries as the disease multiplies in an environment conducive to its spread.
Since the onset of the disease in areas along the Euphrates last August, the infections have risen daily, now exceeding a thousand cases. Laboratories confirmed the presence of cholera in more than ten Syrian provinces, including Aleppo, Deir ez-Zor, al-Hasakah, Raqqa, Latakia, and Damascus. The sharp escalation of the disease prompted United Nations (UN) bodies to warn of a looming pandemic. The UN urged the concerned parties to take urgent measures to contain the disease and ensure sustainable and unimpeded access to affected communities.
On 7 October 2022, the World Health Organization (WHO) stated that there have been more than 15,000 suspected cases and over 60 deaths from cholera in Syria.
In the same context, the Early Warning, Alert and Response Network (EWARN) published statistics on 22 October 2022 saying that the number of cholera cases in northeastern Syria have reached 15483, of whom 28 have died since the outbreak in the region. These cases were reported in the cities of Raqqa, al-Thawra, Deir ez-Zor, al-Mayadin, and al-Bukamal. Moreover, the cities of Tell Abyad and Ras al-Ayn/Serê Kaniyê in al-Hasakah province have witnessed 408 cases of infection and 2 deaths.
In northwestern Syria, the number of cholera cases has increased to 2272, with 2 deaths recorded.
Earlier, on 22 October 2022, the Syrian Ministry of Health stated that the cumulative total number of confirmed cholera infections reached 942 in 13 out of the 14 Syrian provinces. According to the Ministry, Aleppo bore the brunt of the cases with 37 deaths out of the 44 recorded throughout the country. Most of the deaths were of people who delayed getting medical advice or those who suffered from chronic diseases.
In the same vein, on 27 September 2022, the Autonomous Administration of North and East Syria (AANES), also known as Rojava, announced the detection of more than 5365 suspected cases of cholera in the areas under its control. Later, the co-chair of the Health Authority, Joan Mustafa, said in a statement to the Rojava TV channel, that the number of confirmed cases of cholera rose to 105 cases.
Circumstances Accompanying the Outbreak of Cholera in Northeastern Syria
STJ contacted people who were already infected as well as medical workers in northeastern Syria, to delve into details of the cholera outbreak, its causes, and the health sector’s readiness to contain the disease.
Jasem M., 20 years old, was diagnosed with cholera along with 11 members of his family, who are currently residing in the al-Tala’i camp, where they are now staying after they fled their village, Umm al-Keif, located in Tell Tamer, northern rural al-Hasakah.
Jasem recounted to STJ:
“On 1 August, I felt sick with severe diarrhea, severe stomach pain, and hearing and vision deficiencies. I rushed to the Kurdish Red Crescent (KRC) center in the camp, but they did not refer me to the public hospital in al-Hasakah. The symptoms got worse, so I went to a specialist doctor’s private clinic, which cost me a lot of money. My medical analyses confirmed that the symptoms were of cholera, which I got from the water that we bought in the camp from tanks after we ran out of clean drinking water provided by humanitarian organizations. The water that enters the camp (via some people) in tanks is undrinkable and its sanitation is not monitored. 11 people from my family alone, including my mother and brother, contracted the virus from this polluted water.”
Munifa A., a resident of al-Tala’i camp contracted cholera, showing symptoms of stomach pain, vomiting, severe diarrhea, and poor eyesight. Munifa testified to STJ saying:
“On 7 August, I woke up with a sharp pain in my stomach. I immediately went to the KRC center in the camp, but it refused to give me a referral to the hospital on the pretext that there were no referrals available. After that, my health deteriorated further. I went to a gastroenterologist in al-Hasakah despite my poverty and the struggle to come up with treatment costs. The doctor and the medical analyses diagnosed me with cholera, which was transmitted to me through contaminated water. My son had to borrow seven million Syrian pounds to cover the costs of my treatment. I underwent special tests and stayed in the hospital for seven days under observation until I recovered completely.”
Munifa’s daughter, 15, was also infected with cholera the same day as her mother, exacerbating the dire financial conditions of the family. Munifa reported that the medical services in the camp are very bad.
The director of the health office in al-Tala’i camp in Ras al-Ayn/Serê Kaniyê, Dalawar Farhan spoke to STJ about the way the office responds to the spread of cholera cases in the camp. Farhan confirmed that 15 suspected cholera cases were recorded since the outbreak of the disease last month. Dalawar explained:
“We examine the suspected cholera cases in an operating room jointly run by KRC and the WHO located in al-Hikma Hospital in al-Hasakah city center. The infected people are taken to al-Hikma Hospital where they receive treatment under the supervision of the WHO, and they are returned to the camp after their recovery.”
Regarding the prevention measures, Dalawar said:
“We monitor the quality of water and food, especially vegetables, in the camp. There are health awareness teams that roam the camp periodically and closely monitor the quality of water since it is the original source of infection. Unfortunately, after Turkey suspended the al-Alouk water station in al-Hasakah, residents of the camp have had to rely on water from an unknown source for drinking and domestic use.”
STJ’s researchers found that both the Washo Kani and the al-Tala’i camps suffer from an acute shortage of medical services due to the absence of UN recognition of them. Therefore, communicable diseases are prevalent among the two camps’ residents; the daily crowds in front of the KRC confirm this.
The province of Deir ez-Zor also witnessed dozens of cholera cases, which prompted the authorities to raise the alert level at every medical center.
Yasmeen S., 19 years old, who hails from al-Hussan village in western rural Deir ez-Zor, was one of those infected. STJ spoke with Yasmeen’s brother, Ahmed, who said:
“On 28 September, my sister showed symptoms like severe diarrhea and fatigue, which caused her to collapse. We took Yasmeen to the al-Madeena Hospital in al-Ma’amel area. The medical examination and analyses confirmed she had cholera. She stayed in the hospital for three days, during which doctors provided her with the necessary treatment and monitored her health until she recovered. She was discharged from the hospital after analyses confirmed she was out of danger.”
Ahmed attributed his sister’s infection to climate change and the pollution of water coming from the Euphrates River into their homes without being filtered or monitored.
The cholera outbreak has resulted in the deaths of several people including Hussein al-Rajeja, 80, from al-Azba village in western rural Deir ez-Zor. Hussein’s daughter, Sumayyah, recounted to STJ the story of her father’s infection and subsequent death, saying:
“On the 8th and 9th of September, my father had acute stomach cramps, nausea, and weakness in his feet. We thought that the symptoms were of a kind of poisoning, and we bought him serums and some medicines from the pharmacy in the village. However, that did not help, and his condition deteriorated. A week later, we took him to al-Kasra Hospital in western rural Deir ez-Zor which is 50 kilometers (one and a half hours) away from us. My father was placed under medical observation, but he did not receive the proper treatment because of the large number of existing infections. Although we bought my father all the medicines he needed, including antidiarrheal injections, Flagyl capsules, and serums from outside the hospital, the doctors could not save him. The disease defeated my father; he died on his second day in the hospital.”
Sumayyah added that the doctors at the hospital confirmed that her father developed the infection from the polluted water of the Euphrates.
The Shortage of Medical Staff in Deir ez-Zor
A medical source in al-Kasra Hospital, who asked to remain anonymous, spoke to STJ about the outbreak of cholera in Deir ez-Zor since early September 2022 and the vulnerability of the health sectorThe source explained:
“The first week after the detection of the first cholera case was very hectic. Since cholera is of an epidemic nature, it spread rapidly in the al-Kasra area. Within the first three days, there was an explosive outbreak of the disease among the population of the western line of Deir ez-Zor. We took samples from the Euphrates River seven days following the onset of cholera. Examinations confirmed that the Euphrates was contaminated with cholera. We took samples from the drinking fountains in the villages of al-Kasra, al-Jinynah, and As Sawa as well, and they all tested positive for the bacterium causing the disease. This confirms without a doubt that contaminated water is behind the spread of the disease.”
With respect to the actions against the epidemic, the source testified that there was a swift response from international medical organizations to provide emergency aid. He pointed out that the organizations provided serums in large numbers, and that the biggest support was provided by Medical Relief International, which provided 30 beds for cholera patients.
According to the same source, the Health Committee in Deir ez-Zor provided a rapid response to a cholera outbreak. The co-chair of the Committee, Dr Muhammad al-Salem, made daily visits to al-Kasra Hospital and other health centers. Al-Salem ordered the immediate supply of anti-cholera drugs to health centers and scheduled the centers’ work hours to be 24/7 so that the patients could come any time and avoid the massive costs of private clinics.
The source said that the hospitals’ accommodation capacities are good. However, he attested that there is a need to increase the medical staff and establish special medical centers for epidemic diseases.
Regarding cholera prevention measures, the medical source stressed the importance of maintaining personal hygiene and good cooking of food, as high temperature eliminates bacteria. This must be accompanied by the correct procedures for sterilizing water while avoiding adding large amounts of chlorine to avoid poisoning.
Prevention and Treatment Procedures
Internist Dr. Abdullah al-Hallo, who resides in al-Qahtaniyah town in rural Qamishli, spoke with STJ on the reasons behind the spread of cholera and the methods of prevention and treatment. He indicated that cholera cases are usually collective and come in outbreaks. This indicates that the infection comes from the same source, which is likely to be contaminated water or food.
Dr Abdullah explained:
“The most common cause of cholera is food contamination with sewage water, as well as the mixing of the latter with groundwater. Cholera causes severe diarrhea, increasing stool frequency to 30 times a day, which leads to dehydration.”
The doctor added that cholera is an old disease and that cases of infection can be controlled if it is treated appropriately. The infected must adhere to his/her course of medication and ensure constant personal and food hygiene.
The Euphrates Lost its Sweetness
On 21 September, the co-chair of the Health Authority of the Autonomous Administration, Joan Mustafa, stated during a press conference that analyses confirmed that the Euphrates water carries the cholera germ and went on to say: “The pollution of the Euphrates was a result of its water’s significant receding and decline. It has turned into swamps in several areas, and this has led naturally to the contamination of the vegetables irrigated with Euphrates water.”
Turkey’s building of dams on the Euphrates in its territories exacerbated the river’s water recession and thus its pollution in Syria. This pollution was exacerbated by the sewage that flows into the river and the oil pollution in areas of oil wells. Moreover, drought and high temperatures caused by climate change, declined the river’s water level to its lowest, knowing that the river used to overflow annually following heavy rains.
According to UN estimates, more than five million people in Syria depend on the Euphrates River as the main source of drinking water, even its pollution.
The Syrian conflict, which has been ongoing for more than a decade, led to the destruction of clean water and sewage infrastructure. According to the UN, almost two-thirds of the water treatment plants, half of the pumping stations, and a third of Syria’s water tanks have been damaged over the course of the conflict. This has forced people to resort to negative coping mechanisms, such as changing their hygiene practices and adopting solutions that are not subject to the slightest safety and monitoring protocols.