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‘We Die From Every Cause.’ Cholera Hits Syria

A health provider in the region speaks about Covid, ongoing conflict, and the latest health challenge, cholera.



Healthcare providers give a child intravenous fluids at a cholera treatment center in Syria. (Photo courtesy of SAMS)

The cholera outbreak in Syria is ongoing, with more than 35,500 cases across the country, according to the latest report from the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) on November 15. There have been 92 suspected deaths from cholera since August 25 in Syria. Forty-two of those deaths have occurred in Aleppo.

Cholera is a bacterial infection, most often contracted from contaminated water, that leads to diarrhea and dehydration. It can be fatal if left untreated. Syria’s outbreak comes amid outbreaks of the disease in Iraq and Lebanon. Cholera outbreaks are also occurring in Haiti, the Horn of Africa, and Yemen.  

There is evidence to suggest that the outbreak in Syria is slowing, with the top five most-impacted governates, which are all the north of the country, seeing declines ranging from -28% to -5% from October 23 to 29 compared to October 30 to November 5.

Though case counts are trending down, suspected cases have now been reported in all 14 governates of Syria, and there have been no fundamental changes to underlying conditions in the country related to the spread of cholera, especially access to clean water sources in refugee camps and the ongoing armed conflict, which limits population movement.

In the northwest part of the country, including the governates of Aleppo and Idlib, there have been 11,405 suspected cases and 12 cholera-associated deaths, according to OCHA. Of the confirmed and suspected cases, more than half have been children under five years old, according to data provided by the Syrian American Medical Society (SAMS), a nonprofit whose members have been responding to the humanitarian crisis in Syria, including the cholera outbreak in the northwest and eastern parts of the country.

72% of people who are suspected of having contracted the disease live in refugee camps created by the nation’s civil war, which has lasted more than a decade. More than 6.9 million people are still displaced within Syria, and the war has resulted in a total of more than 13 million refugees, including those internally displaced people, according to UNHCR.

A healthcare provider in Syria taking a young child to an ambulance to treat her for cholera with intravenous fluids. (Photo courtesy of SAMS)

“The basic issue in northwest Syria is access to clean water. In all things related to water, there is a very big gap in Syria. In addition, there are a lot of camps and a continuing war. We have a lot of problems with that. Another issue is awareness of the disease and how to reduce the chances of getting it, in general,” said Dr. Reem Enderun Yonso, a senior health and nutrition officer who has been overseeing the nonprofit’s response to the cholera outbreak.

“With authority, as a health body, you can face any outbreak, but in Syria, we don’t have anything at all. Every year is not like the last year. The war in Ukraine has taken money from Syria. After 10 years, people live in camps, they don’t have any hygiene. They don’t have clean water, they don’t have a house. They drink from anywhere. For children, they treat them in the house. Many times, the case gets worse, and then they go to the hospital, and it’s too late,” she said.

SAMS has been trying to address these problems with a multifaceted approach that combines treatment facilities and door-to-door, or as Yonso said about refugee camps, “tent-to-tent” community education campaigns.

Following World Health Organization and Doctors Without Borders guidelines, SAMS has helped set up a multi-tiered care system in parts of the Idlib and Aleppo governates. This includes oral rehydration points, which are often one-room tents placed near communities with suspected and confirmed cases where healthcare workers prepare and administer oral rehydration salts to patients.

In an ambulance, a healthcare provider in northwest Syria treats a young child for dehydration caused by cholera. (Photo courtesy of SAMS)

If the patients do not improve, they can go to a cholera treatment center or its smaller equivalent, a cholera treatment unit. These facilities, which function as dedicated clinics for cholera patients, offer more treatment options, such as intravenous fluids and medication. Ambulances with intravenous fluids are also being used.

SAMS has also organized community health worker (CHW) teams. These teams go to areas impacted by the outbreak to gather data, such as suspected cases, and share information about the disease, including how to prevent and combat it.

To ascertain whether or not a person has contracted cholera, Yonso said CHWs ask if anyone has had diarrhea and exhibited additional symptoms of illness. Then, they will share information about treatment options, such as oral rehydration points. CHWs also educate people about general hygiene, with a focus on handwashing, and ways to treat water, such as by boiling it or adding purification tablets.

A report from SAMS identified several key challenges currently facing those trying to end the outbreak in Syria. Some of these include many patients who refuse to give samples,  hesitancy to be admitted to the hospital, and patients, especially women, who check themselves out of the hospital due to the embarrassment of using the toilet frequently. Some doctors have also been refusing treatment to children due to their belief that only a pediatrician should treat children.

Logistically, the war has made it difficult for many patients to access care centers, water being trucked in by the private sector has been hard to monitor, and there is a general shortage of medicines and medical supplies.

“We already faced Covid for two years, so all of our health system is overloaded. After three months of a Covid lull, there’s a Covid increase, more deaths, and now we’re facing cholera and Covid with limited funds and supplies,” Yonso said, adding that fears of a potential closure of the border with Turkey in the new year are an ongoing concern, particularly since obtaining supplies from Damascus is very slow and unreliable.

As another fraught winter sets in, Yonso said many people had expressed an awful kind of fatigue.

“People don’t know what to be afraid from, Covid, cholera, the regime… even if I talk about cholera, they say, ‘Okay, we die from every cause.’ They don’t take it seriously,” she said.  

Direct Relief has responded to the current cholera outbreak in the region by shipping more than $440,000 worth of medicines, oral rehydration salts, and medical supplies to SAMS, with more on the way. Cholera treatment support has also been shipped to hospitals in Lebanon and Haiti caring for patients with cholera. Direct Relief’s cholera treatment kit contains sodium lactate solution, oral rehydration salts, antibiotics, medical supplies to administer medications, and PPE, and is designed to serve approximately 280 patients.

Since 2010, Direct Relief has shipped over $190 million worth of humanitarian aid to Syria, including over 80.5 million doses of medicine.

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