Twelve years of war, starvation, poverty, COVID, and, in large swaths of the country, decimated infrastructure: Now, Syria is facing its next catastrophe. Cholera has been rapidly spreading across the country's northeast and northwest, hitting the regions surrounding Aleppo, Idlib and Al-Hasakah especially hard.

Syria's first outbreak of cholera was registered on September 10. According to the aid organization Caritas International, more than 15,000 cases have been documented since — and infection rates are climbing. More than 60 people have already died. The threat of cholera spreading across the whole of Syria and even into neighboring countries is very real. Hundreds of cases have already been registered near Lebanon's border to Syria. Cases have also been recorded in Iraq.

Doctors Without Borders setting up cholera treatment centers in Syria

Cholera is an acute gastroenteritis triggered by cholera bacteria, which in turn causes severe diarrhea, vomiting and dehydration. Infection often occurs through contaminated drinking water. "The illness is highly contagious and can quickly develop into an epidemic," as Lucia Ringtho of Doctors Without Borders (MSF) told DW in an interview. Ringtho is an MSF medical advisor for Syria.

Doctors Without Borders and local health officials in Raqqa have set up a cholera treatment center and two outpatient treatment sites in the Kurdish Autonomous Administration of North and East Syria. Caritas Syria is also active in the region, educating locals as well as distributing medicine to protect against infection and tablets for disinfecting drinking water.

Syrians consume contaminated water and vegetables as prices skyrocket

Caritas Syria is also working in government-controlled Aleppo. "Cholera has become a big topic there over the past couple of weeks," as Caritas Syria Advisor Angela Gärtner told DW. Infrastructure in eastern Aleppo is still greatly damaged. The eastern part of the city, which was under the control of various rebel groups until late 2016 to early 2017, was heavily bombed by Moscow and Damascus.

Water and energy supplies are slowly being rebuilt, yet drinking water is still unavailable in many households, says Gärtner. "In some cases, food prices have gone up nearly 500% over the past two years. People can hardly afford to eat." The same goes for clean water. "That's why people are drawing on insecure water supplies and often buy contaminated vegetables."

Many suspect the origins of the outbreak can be found in the Euphrates. There are no water treatment facilities in rural areas along the river, yet many communities draw their household and drinking water directly from it, or from open canals. In cities, destroyed infrastructure leads to tainted drinking water and contaminated food, says Lucia Ringtho of Doctors Without Borders.

The children's aid organization UNICEF estimates that two-thirds of the country's water treatment facilities, half of its pump stations and one-third of its water towers have been damaged by the war. Many cities also lack functioning sewer systems. "All of the wastewater essentially flows straight into the Euphrates," says Gärtner.

Turkish control makes water a rare commodity in Al-Hasakah

There are also massive water shortages in Al-Hasakah. Moreover: Turkish troops occupied a nearby strip of northeast Syrian borderland in 2019, because Turkish President Recep Tayyip Erdogan views the Kurds self-governing the region as terrorists that must be fought.

Turkey controls the regional waterworks there and it is said that it has practically turned off the spigots. That has meant that water in Al-Hasakah, for instance, must be drawn from wells and then distributed among the population. 

The situation for internally displaced Syrians in refugee camps in the northwestern region near Idlib at the Turkish border is especially dramatic. There, many people are often forced to share a single tent and clean water is rare, making sanitary conditions a problem. The region is largely under the control of the Islamist militant group Hayat Tahrir al-Sham (HTS), itself an offshoot of the Al-Nusra Front. UNICEF says that 26 cholera treatment centers are to be set up in the area.

Lack of a healthcare system allows cholera to spread

If detected early, cholera can be handled effectively with access to medial treatment. If not, extreme dehydration can lead to death within a matter of hours. Gärtner says the coronavirus has made people in Syria acutely sensitive to such issues. "But," she adds, "there is essentially no healthcare system, especially in hard-hit areas. That means when cases arise, people have little chance of getting swift medical assistance." Cholera vaccines are also in very short supply.

The World Health Organization (WHO) has now decided to temporarily recommend one dose of cholera vaccine rather than two. That means more vaccine will soon be available for global distribution. The European Union, too, has just made another €700,000 ($688,200) available to fight cholera in Syria.

Russia standing in the way of reconstruction in Syria

Still, to get at the root of the problem, reconstruction of the country must be expedited. But that would entail fulfilling a wish expressed years ago by Russian President Vladimir Putin, namely relieving Moscow of the financial burden of Syrian reconstruction. Russia bombed large areas of Syria while fighting alongside Syrian President Bashar Assad — without Russia, it is unlikely Assad would still be in power.

That is why the EU and its member states have made participation in Syria's reconstruction contingent upon concrete steps toward a negotiated conflict settlement and the political opening of the country. Yet, as the these steps seem to be nowhere in sight, the bloc has limited its support for Syria to emergency assistance. That creates a dilemma: "Emergency assistance doesn't help build water treatment facilities," says Gärtner. "We need functioning infrastructure — so that people can rebuild their lives and are no longer dependent on the ever dwindling drip feed of humanitarian assistance."

This article was translated from German by Jon Shelton