New York Times
Accessed 4 January 2014
Syria’s Raging Health Crisis
By ADAM P. COUTTS and FOUAD M. FOUAD
Published: January 1, 2014
BEIRUT, Lebanon — The public health disaster in Syria has been a long time coming. In three years of violent conflict, 125,000 have been killed and millions displaced. The recent outbreak of polio has focused the world’s attention, and the international response is welcome. Yet this crisis was both predictable and preventable.
The collapse of the health system and a lack of basic sanitation in opposition-held areas have created prime conditions for outbreaks of vaccine-preventable diseases. Syria eradicated polio 14 years ago; the fact that it has returned represents more than a breakdown of health care during civil war. It is symptomatic of how the international community, in its response to the crisis, has neglected public health.
Immunization coverage in what are now mainly opposition areas was already below accepted standards in 2011, but the situation has deteriorated. Data on routine immunization from the World Health Organization reveal that over the past two years a large proportion of the Syrian population has gone without vaccination.
Across Syria, coverage went down to 60 percent in 2012, and was as low as 50 percent in the embattled eastern city of Deir al-Zour, a front line between government and rebel forces. The latest W.H.O. figures from 2013 show that the level is now down to 36 percent in largely rebel-held Deir al-Zour Province, although it has remained at 100 percent in government-controlled areas such as the western stronghold of Tartus.
Given these conditions, it was no surprise to medical practitioners that a polio outbreak occurred. The question is why the international community did not prepare better for this eventuality. A disturbing part of the answer is that the United Nations itself has aggravated the situation.
Like other United Nations agencies, the World Health Organization works directly with the Syrian government. The W.H.O.’s Syria office is in the Ministry of Health building in Damascus; many of its staff members are former ministry employees. A recent Reuters report on how the Assad government uses red tape and threats to prevent the provision of aid in opposition areas has raised doubts about the ability of the W.H.O. to act with impartiality.
The W.H.O., working with the Syrian government, excluded Deir al-Zour from a polio vaccination drive that began in December 2012. According to the W.H.O., the province “was not included in the campaign as the majority of its residents have relocated to other areas in the country.” Ten months later, this was the province where polio re-emerged.
There is no evidence that most of the province’s one million residents had, in fact, migrated. The United Nations World Food Program continued to distribute food there throughout 2012 and 2013 (with occasional interruptions because of worsening security conditions). In December 2012, the agency reached 69,000 people in Deir al-Zour.
Last month, an investigation by the German weekly newsmagazine Der Spiegel charged the W.H.O. with obstructing the testing of polio samples from the Deir al-Zour region. These samples had been presented by an agency working under the aegis of the Syrian National Coalition. It took nearly a month to get the test results — positive for poliomyelitis — and then only from an independent provider in Turkey. By that time, thousands of displaced people had moved within Syria or fled as refugees to neighboring countries, most likely spreading the disease.
The latest draft of a W.H.O. situation report for Syria reveals that it took three months for the W.H.O. and the Syrian Health Ministry to confirm a polio case detected in Aleppo in July 2013. It was then some weeks before a nationwide vaccination campaign began.
The consequences of these delays and failures now reach well beyond Syria’s borders. Lebanon and Jordan, where a large proportion of Syrian refugees have fled, are particularly at risk. Their public health systems are already overloaded and underfunded. Unicef figures for immunization from the Lebanese Health Ministry indicate that only 77 percent of the population had been routinely covered for polio in recent years, placing thousands of Lebanese children at risk. “If the Unicef figures are correct, then this would be far too low to keep an introduced infection at bay,” said Professor Martin Eichner, a disease expert at the University of Tübingen, Germany. “With 4,000 Syrian refugees a day leaving the country, and the majority entering Lebanon, the virus is already in Lebanon or they will get it sometime soon.”
There is also no discernible plan for delivering vaccination coverage to the hundreds of tented settlements that house as many as 200,000 Syrian refugees across Lebanon.
The emergency is not limited to polio. While Syria’s polio outbreak has been making headlines, other communicable diseases like hepatitis A, the parasitic infection leishmaniasis, typhoid and measles have all been rising. Chronic and noncommunicable diseases such as diabetes, hypertension and cancer have also been silently killing Syrians by the tens of thousands. We know from previous crises that up to 80 percent of excess deaths are attributable to wider health conditions during and after a conflict.
The situation is extremely challenging, but humanitarian agencies in the region should be independent and transparent. There are very real challenges for United Nations staff members working in Syria, but the World Health Organization must respond to the claims that it refused to test the Deir al-Zour polio samples, explain why it took three months to confirm a suspected case in July 2013 and give a better account of why the area was excluded from its vaccination drive.
Anything short of this disclosure risks causing more preventable deaths, not just in Syria but across the entire region.
Adam P. Coutts is a researcher at the London School of Hygiene and Tropical Medicine. Fouad M. Fouad, a Syrian doctor, is an assistant research professor in the faculty of health sciences at the American University of Beirut.