The Fatal Threat to All Sides of Syria’s Conflict: Part 1

In the first installment of our Q&A series on infectious diseases in Syria, medical researcher Dr. Annie Sparrow discusses Zika, TB, meningitis and other illnesses that have emerged since the conflict began, and how failure to treat these diseases will have a lasting effect on the population.

Written by Alessandria Masi Published on Read time Approx. 7 minutes
Men breath with oxygen masks inside a hospital in Aleppo, Syria, after a suspected chlorine gas attack. Aleppo Media Center via AP

BEIRUT – Among the multitude of opposing factions threatening the lives of Syrians, there is one deadly group targeting everyone in Syria, regardless of location, allegiance, religion or gender: infectious disease.

Wartime living conditions have significantly increased the risk of infectious diseases in Syria. There have been 382 attacks on 269 medical facilities in Syria between March 2011 and July 2016, severely decreasing the capability of doctors to treat these illnesses. What’s more, Siege Watch estimates that more than 1 million people are living in besieged areas, where diagnosis and treatment for infectious diseases are scarce and dire living conditions have created a breeding ground for such maladies.

Syria Deeply spoke with Dr. Annie Sparrow, an associate professor and deputy director of the human rights program at the Icahn School of Medicine at Mount Sinai, who currently focuses on the Syrian conflict, about the state of infectious disease control in Syria and the effects this will have long after the war has ended.

Syria Deeply: What are the most dangerous diseases that have either emerged or become more widespread in Syria since the war began that you’ve come across in your research?

Sparrow: There are diseases that have always been there but are much worse now, like typhoid and taeniasis [a parasitic disease] and tuberculosis (TB). The worrying thing about diseases like TB is that the number of cases reported by the World Health Organization are basically government figures and are consistently underreported.

There was a statement made recently by Damascus saying there has been no increase, but, of course, they’re not recording or reporting any of the cases outside of government territory. There’s a lot more than 3,000 cases across the country. It’s been cultivated for the last few decades in all of the Syrians held captive in the prisons, so what we are seeing is a more drug-resistant TB, which is much harder to treat. If you don’t treat it well, with the right drugs every day, then it becomes more drug resistant. It’s a very difficult disease already, and it’s on the rise again in the rest of the world, too, like measles, and so many infectious diseases.

Most recently what we’ve seen in Latakia and Idlib are signs of Guillain-Barré syndrome, the name we give to cases of acute flaccid paralysis, when you lose control of your arms or legs and sometimes your respiratory muscles. It can have any number of causes. Sometimes it’s diarrheal illnesses like campylobacter [a bacterial intestinal infection] or others.

That’s quite worrying. They’re mostly younger people, the average age is, I think, 23. But there’s a range of between seven months, normally we don’t see Guillain-Barré that young, to 58. More males than females are affected. Most of them are from Idlib, but there’s also been cases in Aleppo, Hama, Homs and Latakia. The reason why it’s very worrying is that’s one of the common manifestations of Zika.

Syria Deeply: Is there a possibility that Zika is in Syria but just isn’t being reported?

Sparrow: The mosquitos that carry Zika are the same mosquitos that carry yellow fever and dengue fever. They’re tough mosquitos, they jump on sailing boats, and that’s how they cross oceans. That’s how they sailed their way to Brazil from the east coast of Africa.

It would make sense if we started seeing Zika in coastal areas like Latakia, which is the biggest port. But it’s just one of the causes of Guillain-Barré, we don’t actually know. So, what we’ve seen in Syria could be anything from Zika to enterovirus to something else.

Syria Deeply: Last summer there was a huge outbreak of cholera in Syria. Has this been reported again?

Sparrow: We thought we’d see it again this summer, but we didn’t. It’s just being covered up so well that nobody knows about it. That’s what happened last year. Last year even with the cholera that was [in eastern Deir Ezzor], WHO in Damascus kept saying, “There’s no cholera, there’s no cholera, there’s no reports. We’ve got people everywhere.” Which is such nonsense.

Meanwhile, my colleagues in Deir Ezzor were saying there was cholera, and they would give me the cases. I’d say, “Why do you not want to report it? Can you not report it?” [They replied,] “We know it’s across Iraq, we don’t need to keep doing diagnostic tests when it’s already been extensively and comprehensively proven.”

They consider the border [between Iraq and Syria] to have been obliterated. So, pragmatically, if you know that cholera has already been tested in thousands of cases across Iraq, you don’t need to test it again if you’re operating [in Deir Ezzor] because you already know what you’re dealing with.

Syria Deeply: In Madaya, a besieged town outside of Damascus, there have been several cases of meningitis and some patients were evacuated. Has this helped to stem the outbreak?

Sparrow: Now that’s very serious. Meningitis kills; children and adolescents are particularly vulnerable. In the rest of the world, we have meningitis vaccines that are routinely given, for example, to teenagers and college students because they share dormitories, they live in crowded conditions. This is a disease that is spread by droplets, like coughing and sneezing on each other, or close contact. It can be absolutely devastating.

Madaya has been under siege for a long time and it’s surrounded by landmines. It took a long time to get any of these patients with meningitis evacuated from Madaya and most of them went to Damascus. We’re not hearing anything about them.

Evacuation of these patients took a long, long time, which is insane, because, like everything else, it has become a political response rather than a medical response. When you evacuate someone, you do it on medical criteria. They need evacuating and they need it now. You can’t wait a week, because your patient will die and that’s what frequently happens. Whether they’ve been shot in the back or they’ve got meningitis or they’ve got terrible malnutrition, or whether it’s a mother with critical pregnancy complications, they’ll die, and they do.

The latest convoy that went to Madaya in September didn’t contain any kind of antibiotic treatment for [meningitis]. We know that new cases are still happening.

Syria Deeply: Why weren’t those drugs included?

Sparrow: Because the government … can’t be bothered. There were 180 bottles of Amoxycillin. Amoxycillin doesn’t work against meningitis. The risk of getting a disease like that, whether it’s measles or meningitis, is amplified when you live in unsanitary conditions with terrible water, not enough soap. There’s not enough water to cook or drink, let alone for personal hygiene, showers and to wash everything to get rid of all of the bacteria and viruses.

Syria Deeply: Water plays a major role in both the treatment and spread of infectious disease. How has the war amplified what you call “terrible water” in certain areas?

Sparrow: Chlorine for treatment at the water sources is held by the government and it’s a very effective method of indirect biological terrorism.

At the same time, the water sources around Aleppo, for example, have been repeatedly bombed. And some of those provide water for hundreds of thousands or so residents. Rehabilitating the water source takes a very long time and cannot be done right now. The deliberate attacks on the water parks just show that the government couldn’t care less about the spread of disease.

Syria Deeply: So chlorine isn’t being used as a way to purify water, but it is used as a chemical weapon in certain parts of Syria. What long-term or lasting effects will chlorine and other chemical weapons have on people’s health?

Sparrow: It’s hard to know. The only data we have comes from World War I and Iraq. Chemical agents like sulphur mustard [mustard gas] have horrific effects in the short and long term. They cause chronic lung disease, cancers, blindness and so forth.

Sarin has an effect on various parts of the body: Muscles, for example, but some of it is also stored in fat and gets released in the blood stream, and then you have a different effect. We don’t know enough about that. With people who survived the first 24 hours, we saw that it’s so effective at killing quickly because it’s a neurotoxic agent, it paralyzes muscles and does a lot of nasty things. But the next day and the next day people would come back with different symptoms. Some would come back in 48 hours with delirium and disorientation.

We even saw that people who had received blood from those that had been exposed to sarin had heart arrhythmias and irregularities. I’m just saying what doctors there saw. I wasn’t there but [that’s] what they told me.

Chlorine doesn’t kill people very often – It did kill two kids on August 10 – but it’s incredibly effective in terms of short-term fear, when a gas descends and you don’t know what it is. That’s one of the things that’s so frightening, we don’t know what the long-term effects are.

Syria Deeply: Doctors in Syria are aware of these different diseases but are stretched to their extremities as hospitals and medical personnel continue to be targeted. And treating trauma injuries, of course, takes precedence. How has this affected the spread of infectious disease?

Sparrow: It’s a big problem. It’s not possible to manage these diseases under such conditions. There are just not enough human resources, and the targeting of doctors and hospitals means that more are lost every week.

The Syrian government’s infection control attitude is beyond irresponsible and reckless. It’s deliberately creating the conditions where all of these diseases can breed and thrive. You force thousands, tens of thousands, and millions of people to live together in crowded conditions so diseases spread much more rapidly, not just by being airborne but also by close contact.

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