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September 2022
The Syrian Ministry of Health declared a cholera outbreak on 10 September, after 15 suspected cases were confirmed by laboratory testing. Government data indicates 39 cholera-related deaths to date, with thousands of suspected cases reported across the country – although at the moment, cases appear to be concentrated in the north of the country and around the Euphrates River.

Exploring both historical and recent data collected by REACH in northeast Syria, our September Media Bulletin delves into the likely drivers of this outbreak: ongoing drought and ensuing water shortages, along with poor health and sanitation conditions in the country after 11 years of conflict.
According to the World Health Organisation (WHO), cholera is a disease caused by bacteria that can be found in faeces, and spreads through people consuming contaminated water or food. It causes severe watery diarrhoea and vomiting which lead to dehydration. If treated immediately, less than 1% of cases result in patients dying. However, if timely treatment is not available, cholera can lead to death within hours in 25 to 50% of cases.
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Water shortages are leading to reliance on unsafe sources, in turn driving up cholera risk.

A drought beginning in late 2020, long-term reduction in groundwater levels, reduced flow in the Euphrates River, and reduced functionality of Alouk water station have all contributed to Syria’s water crisis. To cope with shortages, Syrian households have increasingly relied on unsafe sources, like water delivered by trucks from private vendors: in northeast Syria, 37% of communities assessed by REACH this month reported trucked water as their main drinking source. However, water quality is not monitored, and the source of privately trucked water is not always known – vendors may be using surface water, which is easily contaminated. 

In Syria, one the primary sources of surface water, the Euphrates River, is known to have raw sewage discharged into it. The risk of cholera infection through consuming untreated water from the Euphrates is therefore very high and made worse by the current low water levels, which can lead to a higher concentration of bacteria. In fact, REACH data reveals a link between communities relying on water trucking and those reporting that water was perceived to be making people sick: 

  • 20% of assessed communities that relied on private trucking felt that the water was making people sick, compared to 5% in communities reporting other primary water sources 

  • 38% of sites for internally displaced persons (IDPs) using trucked water reported this as well, compared to 19% of IDP sites using other primary water sources  

  • Data collected this month also found reported cases of diarrhoea in three-quarters of assessed communities.

More than a decade of conflict has destroyed critical health services and sanitation infrastructure.

The burden of disease is particularly high as access to healthcare remains weak, due to poverty, lack of funding for health facilities, destroyed facilities, and a lack of health workers. Given that cholera treatment is needed immediately to prevent deaths, widespread lack of access to health services in areas experiencing the outbreak is especially concerning: 

  • Nearly 90% of assessed communities and 95% of IDP sites reported that health services were unaffordable, followed by 78% and 72% respectively reporting a prohibitively high cost of transportation to health facilities  

At least half of all sewage systems nationwide are out of order. REACH data also shows that in northeast Syria, 79% of assessed communities reported their location was not connected to a sewage system, increasing the risk of contaminating water and food sources if sewage is not safely managed. The situation was found to be more concerning in IDP sites where displaced households were also lacking latrines – for example, 40% of locations in Deir-ez-Zor reported no available latrines and 44% of sites reported the practice of open defecation within the site as an alternative. Open defecation in particular raises the risk of spreading diarrhoeal diseases like cholera.  

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