How Cholera Came to Torment Syria

Unchecked contaminated water has spurred an epidemic

How Cholera Came to Torment Syria
A Syrian Child receive treatment at cholera ward of Al-Rahma Hospital in the city of Darkoush. Photo by Anas Alkharboutli/picture alliance via Getty Images

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“The war didn’t leave us anything to fear,” says Mohammed Redouan as he contemplated the rapid spread of cholera in his hometown of Aleppo. The retired septuagenarian nurse recalled the last time a wave of cholera tore through the country 15 years ago.

In 2007 and 2008, incidences of cholera broke out in the governorates of Raqqa and Deir ez-Zor, as well as large swaths of the East Aleppo countryside. At that time, Redouan was employed at the Anti-Tuberculosis Center in Aleppo, an office of the Chronic Communicable Disease Department of the Syrian Ministry of Health (MoH). He also moonlighted as a nurse in a private clinic. 

“The word ‘cholera’ used to strike fear in peoples’ hearts, such that there was a commitment to most preventative measures, [but] everything has changed,” said Redouan. “Take my family, for example. When the disease broke out before the war, we would avoid drinking water straight from the tap for many long months. When outside the house, we used to drink mineral water, which was dirt cheap at the time. When at home, we used to boil water, freeze it, then place it in water bottles.” 

“We would be nuts to do something like that today,” he added. “Boiling water consumes a lot of gas or electricity, both of which are in short supply. As for mineral water, it has become exorbitant. My pension wouldn’t allow me to drink even just one bottle of water a day.”

Most people now simply avoid purchasing leafy greens or place greater emphasis on washing the vegetables that are bought in limited amounts. Redouan believes the lax concern for the disease is natural, since “nobody fears the disease any longer. They don’t even fear death. We have been around death so long that we’ve gotten used to it.”

Aleppo Governorate topped the list of cholera cases in the regions under the control of the Bashar al-Assad regime in Syria. The latest MoH statistics (published on Nov. 19) indicate that the total number of confirmed cholera cases in Syria has reached 1,456 patients, 884 of whom are in Aleppo. A total of 49 people have died as a result of the disease, 40 of whom were in Aleppo, though it is believed the actual number is much greater than that.

Contaminated water is considered one of the most important causes of cholera, whether due to drinking it or using it to water crops. In mid-September, the World Health Organization (WHO) representative in Syria, Iman Shankiti, said during a press conference that “the public water system in Aleppo is not polluted.” However, the public waterworks are not the only source of water the city’s residents rely upon, especially with rationing programs still in place, limiting the pumping of water to specific days. In addition, drinking water pipes have been heavily damaged in several East Aleppo districts as well as in most of the rural areas that saw fierce fighting in recent years, which means water contamination is far worse outside urban districts.

Irrigation with sewage or polluted water is also common in Syria. For example, in Aleppo, thousands of acres of farmland are routinely watered with contaminated water because of a historically persistent problem in the region: the drying-up of the Queiq River (whose source is in Turkey). In one of the many failed attempts to resolve this issue, water was extracted from the Euphrates via special pumps and dumped in an area along the northern borders of Aleppo, ironically called “Canadian Falls.” It didn’t take long for this potable water to become polluted with the fluids of the Aleppo sewage system. 

The sewage water gathers in the Ramouseh industrial zone of Aleppo, where a treatment plant was built in 2002 to clean it before repumping the treated water back into the Queiq. Then, it would be poured into the plains of Southern Aleppo, the largest source of vegetables in the governorate. The treatment plant, however, went out of service more than five years ago amid reports that its equipment had been dismantled and stolen during the war. Then, the Euphrates water meant to feed the Queiq became scarcer, as the former faced its own unprecedented drought concerns because of Turkey’s noncompliance with a 1987 agreement to distribute shares of the river’s waters. This agreement was considered temporary and was meant to divide up the Euphrates’ waters between the two nations during the time in which the Ataturk Reservoir was being filled. It originally stipulated that Turkey commit to providing an annual average of at least 15,000 cubic feet per second of water across the Turkish-Syrian border, until the agreement was expanded to ultimately distribute the Euphrates’ waters between the three countries lying along its banks (Turkey, Syria and Iraq). According to a local official within the autonomous administration of Raqqa, the average flow of water has slowed to just 40% of the previous average.

As a result, the plains of Southern Aleppo have been irrigated by untreated sewage water for years, which would provide a logical explanation for the rapid outbreak of cholera in the area. The same scenario is now being played out in several other regions, the only difference being the particulars, as most of the key rivers in Syria are threatened by drought and lower water levels. From the Barada in Damascus to the Khabour and Balikh in the northeastern of the country, to the Orontes in Homs and Hama, parts of these river lands have transformed into something closer to marshes. Much of the agricultural land relies on groundwater mixed with sewage water, a consequence of the destruction of sewage systems throughout the country. In the shanty towns found in many regions and the camps for displaced people in the north, these sewage systems are nonexistent.

Umm Ibrahim and her family live in al-Safira District, about 15 miles east of the city of Aleppo. She says she cannot remember the last time she drank tap water, as it simply “doesn’t reach us.” Like most of the district’s residents, she buys her water from massive tanker trucks. “We buy 1,000 liters every few days and we use them for everything,” she says. In this case, “everything” includes drinking, cleaning, preparing hot beverages and cooking. When asked if she had changed any of her daily habits after the most recent cholera outbreak, she replied with a mix of confidence and indifference, “No. We can’t change even if we wanted to. There’s no alternative. In the end, God will protect us.” 

Tens of thousands of other families in Aleppo and across Syria find themselves in a similar predicament, unable to find a safe and secure source of drinking water. The same is true in places less affected by the war, such as Latakia, where residents have suffered under harsh pre-war rationing programs. Moreover, it is hard for the public water systems to reach the higher levels of certain residential buildings, as existing water pump infrastructure is weak due to poor civic planning.

Hissan, a civil engineer in his 50s and the head of a family of six, explains that he fills his home’s water tank, located on March 8 Street in downtown Latakia, with water he buys from mobile tanker trucks twice per week.

“We use this water for everything,” he says, “except for drinking. We drink from the tap. The water runs one day, then is cut off the next, so we store up enough of it for the following day. That’s how it goes.” The only difference in his case is that he has adopted the new procedures in light of news of the latest cholera outbreak. “We’ve started storing more city water for all of our personal hygiene needs. I bought four large, 30-liter plastic containers for this purpose.”

Aside from drinking water, ice is another possible means for conveying the bacteria that causes cholera to Syrian consumers. Given the ongoing electrical power outages, most restaurants and cafes, and even some families, resort to buying ice blocks made in a factory or workshop. These workshops produce the ice by pouring water into massive molds, then transferring them to freezers.

Over the past few years, the services of these ice workshops have spread because of ever-increasing demand, especially during the summer months, when power outages are more frequent. These workshops are not required to use clean drinking water from a safe source when making their ice. In October, the Directorate of Health Affairs in Aleppo announced it had closed six ice factories that were using groundwater wells. There are many ways for these factories’ products to reach consumers across various segments of society, whether through restaurants and cafes or cheap products like “slush,” a popular drink made from blending tiny amounts of juice with large amounts of shaved ice. 

Despite the risks, the overwhelming collective attitude to cholera, even now, tends toward indifference. The government has imposed a few minor restrictions that include prohibiting restaurants and fast-food outlets from offering leafy greens. 

While adherence varies among restaurateurs (many still serve dishes ostensibly banned by the health authorities), the measures are a boon to them, allowing them to sell sandwiches bereft of greens like mint, pickles or lettuce for the same price.

Ironically, the glut of excess vegetables, as well as a recent ban in neighboring Jordan of Syrian vegetable imports over cholera concerns, has not affected their price, which is governed more by the skyrocketing cost of fuel. Farmers in Syria sometimes refrain from harvesting crops that will not be exported, because the cost of harvesting and transporting them exceeds what they could be sold for. Instead, they prefer to destroy, rather than reap, the crops.

The current cholera outbreak has seen no noticeable or radical changes in home consumption habits for wide segments of Syrian society. Abu Umar, a produce vendor in Aleppo’s Souk al-Azzamiyya market, says the pace of sales and purchases remains normal, except for a lower demand for parsley. Even though it is a key ingredient in meals often cooked at home, such as “ujjeh” (Syrian omelet), parsley is now generally considered a luxury in Aleppo. As such, some housewives add it to salads, not to mention the famous tabbouleh dish, which is usually only prepared for special occasions, large family feasts or women’s game nights. This particular social phenomenon witnessed a sharp decline during the war years, almost to the point of disappearance, a trend that continued even after the fighting died down, mostly because of the economic downturn.

Yet parsley is not the only ingredient that can transmit the disease. There is a long list of crops that are potentially contaminated with cholera, especially those indispensable products that are typically eaten raw. Umm Fadi says she is not afraid of catching the disease and has not changed any of her family’s nutritional habits. 

She says her lack of concern comes from the fact she washes her fruits and vegetables with soap and water and has steeped certain foods in salt ever since the coronavirus outbreak in Syria. She does this in addition to all the other strict procedures put in place at the start of the pandemic. 

Her younger sister, Nadia, jokes that all the exaggerated concern for cleanliness is merely “OCD.” “None of this is necessary,” she says. “I wash everything with water, peel everything that can be peeled and cook everything well enough. In the end, nothing I do will protect me. If I’m infected, then that’s just my fate. That is the most important lesson I learned during the coronavirus.” 

After a few moments of silence, she then adds, “Everything was blown out of proportion at that time. I spent so much money on disinfectants and masks and had three doses of the vaccine, yet in the end, I still caught the disease.”

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