The asymmetry of most modern conflicts blurs the lines between combatants and non-combatants, anchoring the omnipotence of violence in ways that are no longer localized. While state and non-state actors are increasingly resorting to the use of tactics directed against civilian infrastructure for military and political gain, the levels of violence produced against health infrastructure and personnel in Syria have been staggering. Targeting civilians and their vital infrastructure, restricting their access to food and water, and producing mass violence were no longer exceptional war crimes, but brutal daily realities in Syria, as the state’s counterrevolutionary war waged against the population starting in 2011 has particularly featured the strategic weaponization of health. Coupled with the erosion of living standards and mass displacement accompanying prevalent insecurity, the intentional use of health as a weapon of war has not only prevented Syrians from seeking appropriate care for injuries, but also exposed them to emerging and re-emerging diseases, ranging from polio and tuberculosis, to the latest bout of cholera. It has also weakened all infrastructural resilience and health or humanitarian responses to large-scale disasters, as we continue to witness thousands of lives being lost after the tragic February 6 earthquake due to overwhelmed local capacities and deadlocked aid responses, especially in Syria’s northwest, despite the best efforts of the Syria Civil Defense, also known as the White Helmets.
Yet, the extent to which the weaponization of several public goods in Syria, including health and water, has driven the cholera outbreak and entrenched severe public health weaknesses remains underexplored.
A cholera epidemic in the making
Adding to a preexisting endemic of violence, the outbreak of cholera in Syria draws attention to the substantial degradation of living conditions across the country. While the 11th year of conflict in the country has displayed relatively lower levels of armed violence, continued forced disappearances, airstrikes, bombings, and intermittent clashes on various frontlines remain a major source of insecurity. Other forms of insecurity also endanger the lives of millions of Syrians, as they struggle with pervasive poverty, protracted famine, and reduced access to various basic necessities. Amidst rampant fuel and food shortages, over 15.3 million Syrians are estimated to be in need of humanitarian aid in 2023, with over 90 percent of the population living below the poverty line. Additionally, the scarcity of access to clean drinking water leaves a large share of Syrians with no other choice than to rely on alternative untreated water sources, vectors of a wide range of water-borne diseases. The earthquake has further exacerbated these insecurities, with hundreds of families losing their homes, belongings, and sources of income overnight, with significant damages inflicted to already fragile civilian and public infrastructure.
As an infamous disease of poverty, cholera thrives in conflict-afflicted countries where access to safe drinking water and adequate sanitation cannot be guaranteed. It is an acute infectious diarrheal illness that results from the consumption of contaminated food or water, the symptoms of which can initially be mild, including diarrhea, nausea, vomiting, and dehydration, but become life-threatening if untreated, depending on pre-existing individual health vulnerabilities. Cholera spreads particularly rapidly in dense urban and peri-urban settings that lack sewage and water treatment facilities, leaving populations forced to use the Euphrates’ untreated contaminated water. With most parts of Syria still reeling from the consequences of the recent ruthless seismic activity and the collapse of key infrastructure, exposure to cholera remains ever high and the capacity to respond extremely low. Yet, failure to report cases not only increases the risks that sources of contamination will remain unidentified, but also that the disease will continue to spread at rates that will overwhelm local capacities stretched thin while catering to urgent injuries resulting from the earthquake, leading to an underestimation of the real toll of the disease.
The geopolitical spread of the outbreak equally raises concerns about the marked vulnerability of the entire country to health crises and the difficulties associated with containing them, as violence inhibits adequate humanitarian emergency response. Cholera has permeated various governorates, regardless of territorial control. While the first cases were mainly concentrated in Aleppo, the wave of infections soon also overwhelmed northeastern and northwestern Syria, posing a particularly grave danger in the Idlib camps’ informal settlements, suffering from overcrowding, insanitation, and lack of running water. Winterization exacerbates these precarious conditions, as cold temperatures, unreliable energy supplies, and increased humanitarian aid access challenges compound internally displaced people’s vulnerabilities, affecting both physical and mental well-being. Syrians settled elsewhere in the country are no less shielded, as the country’s collapse and politicized attempts at reconstruction have rendered life unbearably unaffordable in areas where critical infrastructure are in shambles.
Less than 60 percent of the country’s hospitals are functional, complicating the prevention, diagnosis, and treatment of diseases. The Syrian ministry of health oversees health planning and responses in areas under the government’s control, while the withdrawal of state support from other parts of Syria has prompted the establishment of parallel health systems sustained by local actors, falling under the de facto control of the established Kurdish-led autonomous administration in the northeast, and that of the Syrian interim government in the northwest, mostly through local health directorates attempting to maintain functional health systems and provide health services, in coordination with humanitarian organizations and the Gaziantep health cluster.
These isolated health systems continue to be sternly challenged by the rapid influx of cholera cases, which amounted to 56,879 suspected cases and 98 deaths by early December 2022. If these health systems were already unable to face one major public health crisis, they sure are even less prepared to deal with two simultaneous ones. While facing difficulties in coping with the cholera outbreak even prior to the earthquake, health facilities across Syria are now facing an afflux of severe injuries in need of urgent medical responses, relegating to the background concerns about the cholera outbreak, despite it also remaining a pressing lethal force operating in the country. The few available hospitals and clinic beds are now prioritizing urgent traumas, leaving those suffering from infectious diseases not only without medical aid, but also with no formal diagnosis or treatment, which could drive the rapid proliferation of the outbreak amidst earthquake survivors. The lack of sufficient medical equipment and health professionals facilitates the development of preventable complications related to the disease, which can be particularly deadly for children and vulnerable populations suffering from multi-layered socio-economic, political, and health crises.
While the outbreak is driven by the consumption of untreated water, the contaminated waters of the Euphrates are but a symptom of a more profound disease plaguing the country: the weaponization and subversion of core public goods, including water and health.
The weaponization of health, water, and everything in between
The country’s hydrology has undergone profound changes over the past decades, as a result of poor governance, intensified (mis)use of water, and climate change-induced drought. The severity of this precarious situation has been compounded by the targeted destruction of key water infrastructure following the radicalization of state violence in the aftermath of the uprisings. The Syrian regime deliberately cut off access to and bombed water sources, such as the Ain al-Fijeh spring in 2016 situated a few kilometers northwest of Damascus, when punishing populations. Other actors, mainly ISIS, also employed water as a weapon of war, by not only destroying pipes and sanitation plants, but also poisoning water sources and calculatingly flooding cities. As such, less than 50 percent of water and sanitation systems are currently functional nationwide. As main treatment facilities have come to a halt, over 70 percent of sewage is untreated waste contaminating natural water sources and poses a grave danger to populations and their environment.
As a result, the availability of drinking water decreased by 40 percent within the span of a decade. Yet, these infrastructural damages have not been remedied. Just like water was used as a weapon to force the opposition into submission and regain control of territories, it is currently deployed as a political tool to coerce and capture loyalties through politicized reconstruction, excluding those opposed to the regime. While one of the main reconciliation promises extended by the Syrian regime was to reinstate public social services in formerly rebel-held territories, the state only confiscated and co-opted the public facilities established by the disbanded opposition councils, including field hospitals and water infrastructure, but in a politicized manner, conditioning access to these services on political allegiance.
Adding to this lack of domestic political will, regional security competition among the Euphrates riparian states creates incentives to instrumentalize water. For instance, northeast Syria’s acute water scarcity is further compounded by Turkish authorities’ attempts to limit water flow from the Turkish-controlled Allouk water station to Kurdish-held territories. Syrians across the country continue to undertake a permanent battle for water, traveling long distances to fetch it, purchasing it from private suppliers, rationing limited supplies, and resorting to unsafe water sources, including contaminated wells.
Similarly to water, health has also been used as an instrument and target of violence. The Syrian state’s violence was distinctly characterized by the systematic targeting of health infrastructure. From the very early days of the revolution, most state-hospitals were militarily subverted as government forces stationed inside to capture incoming patients, or used them as a military base for snipers to fire from, as has been the case for the national hospital in Deraa. Over time, such focus on hospitals as political spaces evolved into full scale airstrikes, bombings, shelling, shootings, and artillery attacks penetrating the vicinity of health facilities, with over 600 attacks conducted between 2011 and early 2022. The Syrian regime and allied forces bear the responsibility of more than 90 percent of these attacks, which have intensified after Russia’s involvement in 2015, bolstering the air and ground campaign aimed at suppressing opposing political and military forces. The persecution, torture, and killing of health personnel, coupled with their enrolment to conduct medicalized killings and torture, as exemplified by the trial of the Syrian doctor Alaa M. for crimes against humanity, have further contributed to exhausting the country’s health capacities. The remains of this fragmented health governance architecture operate in secluded silos, unable and unwilling to communicate key data points to trace and contain outbreaks.
As failure to contain diseases ruthlessly uncovers the failings of a regime, it creates incentives to conceal their spread. During the COVID-19 outbreak, under-reporting was prevalent, owing to a lack of preparedness, testing capacities, but also of political will. The Syrian regime’s strategy today echoes similar lines of political reasoning, as the government fears demonstrating weakness through its inability to provide basic social services to a struggling population. This would undermine the state-propagated narrative presenting Syria as safe for return, at a time when normalization deals with Turkey and the UAE are on the table and when the earthquake has provided rapprochement opportunities for the regime with countries such as Egypt, Tunisia, and Libya.
With cholera cases spreading to Lebanon, and given the precedent set by the global response to COVID-19, the regime also fears facing stringent measures that would further reduce the mobility flows of people and goods. Yet, not only is the state misrepresenting the real toll of the disease, deep public distrust also prevents many in regime-held territory from seeking healthcare due to fear from persecution in infiltrated healthcare facilities, leading to greater disconnect between official public health figures and the reality on the ground.
The politics of humanitarian assistance
Yet, not only is the regime failing to contain the outbreak in the territories it holds, it is also actively repressing efforts to contain it in areas that fall outside of its control. Given the destruction wrought by the weaponization of water and health, rebel-held areas in northwest Syria rely on humanitarian aid. Continued cross-border humanitarian aid delivery rests on the renewal of the United Nations Security Council’s authorization every six months, which the Syrian government has previously attempted and successfully managed, to restrict, by closing off the Bab al-Salam, al-Ramtha, and al-Yarubiyah crossing points. Under the constant threat of Russia’s possible veto, failure to renew access to the remaining Bab al-Hawa access point could deprive the region from essentials needed to contain the cholera outbreak, including treatment, hygiene kits, and chlorine tablets. Even then, the rigidity of the aid provision process leaves no flexibility for emergency aid to pass through, as has been the case following the logistical and political reverberations of the earthquake preventing humanitarian assistance from being delivered in a timely manner. Throughout the first few days following the earthquake, while time was of the essence to provide equipment supporting search and rescue efforts, the only vehicles permitted into Idlib contained the bodies of Syrians who have perished in Turkey, a painful reminder that death has become more attainable than help.
While humanitarian assistance is usually viewed as apolitical, the humanitarian space is in fact regulated by socio-political and economic factors, determining how many resources are available and who controls their distribution. There are two models of humanitarian delivery usually developed to deliver supplies to affected areas. While cross-line aid relies on providing assistance to a central government that controls and manages the distribution of aid across conflict lines within the country, cross-border aid allows the delivery of aid relief from neighboring countries directly to the populations in need, without requiring approval from the regime in power, thereby minimizing averse state interference aimed at isolating populations from humanitarian assistance.
In practice, this means renouncing to cross-border aid in favor of exclusive cross-line mechanisms only. It would effectively grant the Syrian government full control over the delivery and distribution of humanitarian assistance in Idlib. Concentrating this power in the hands of the regime whose very violence creates the need for humanitarian aid would not only legitimize it, but also give it the opportunity to divert aid to the benefit of its own military and political circles. Yet, the Syrian ministry of health has received 2 million cholera vaccines from the UN in November 2022 for its exclusive benefit, with cholera vaccination coverage currently predominantly concentrated in areas under its political control. Similarly, the so-far limited international aid received by Syria, whether sent via bilateral or multilateral canals operated by organizations such as the Syrian Arab Red Crescent, has been channeled into government-held areas. This leaves little possible oversight to ensure it is directed indeed toward relief efforts and not diverted for other purposes, while also further isolating the northwest whose situation remains dire.
As such, concentrating aid in Damascus allows the Assad regime to continue politicizing aid by selectively providing medical and humanitarian aid to areas it wants to reward loyalty in, while withdrawing it from those deemed to be opposing it.
Alternative policy recommendations
There are several levels to addressing the risks associated with the compounding public health crisis in Syria, some focusing on stopping the hemorrhage, and others on cauterizing the wound. The former rests on prioritizing relief efforts and the humanitarian response to health emergencies to rapidly salvage the mass casualties that could result from failure to contain the outbreak amidst the displacement and damages caused by the earthquake.
Ensuring humanitarian aid and medical supplies are equally distributed in government-held areas and reach rebel-held areas is essential to reinforce capacity to treat cases and prevent unnecessary death and complications. This is why their distribution should be impartially managed by humanitarian health organizations and UN agencies and directly allocated to designated local partners in northwest and northeast Syria. This aid should also include providing the resources needed to design and implement water, sanitation, and hygiene (WASH) interventions to treat the water, including the chlorination of critical water sources, the provision of cholera response kits, and the disinfection of water filling points, all of which are indispensable to limit the spread of the disease.
With the risks of the cholera outbreak further spreading, urgent interventions to strengthen surveillance systems are required across Syria to trace cases and improve the accuracy of reporting, via more efficient coordination structures and the systematization of information-sharing canals between health facilities and local authorities and humanitarian partners. This also requires improving prevention, tracing, and treatment capacities, by implementing policies including community door-to-door campaigns to raise awareness about the disease, its symptoms, and ways of transmission.
However, these will continue to represent band-aid solutions if the military and political root causes of the outbreak, and more generally of the marked vulnerability of Syria to public health crises, are not acknowledged and addressed.
Securing clean drinking water requires repairing water infrastructure, including water treatment facilities and sewage systems. However, only humanitarian organizations seem to be involved in efforts to temporarily rehabilitate some pumping stations, as water remains a weapon and political tool used to exercise control. The health of Syrians across the country will undoubtedly continue to be threatened as long as health and water continue to be used as instruments of violence in full impunity and if no multilateral efforts are undertaken to protect health and humanitarian aid workers, investigate attacks directed against civilian infrastructure, and prosecute perpetrators of similar crimes against humanity.
Similarly, humanitarian aid needs to be shielded from power plays and politics if it is to truly help alleviate people’s suffering and protect the millions of people whose lives are endangered by the complex humanitarian political limbo they are forced to navigate. Long-term aid mechanisms need to be secured as opposed to ad-hoc relief efforts developed exclusively for short-term emergency responses, when the entire Syrian public health governance landscape is in a severe protracted crisis. This requires exploring legal alternatives that exist outside of the framework of the UNSC, by focusing on how UN agencies can independently pursue procurement, funding, and coordination efforts, on the basis of international humanitarian law. One such alternative could be to have a substitute pooled fund that sustains contingency planning and empowers local partner organizations in the northwest of the country to reduce dependency on current provisional aid mechanisms and report access gaps.
While funds should continue to be primarily directed toward urgent needs, the cholera outbreak serves as a cautionary tale. Averting future health and socioeconomic crises requires a reengineering of short-term humanitarian assistance models, to include capacity-building projects that provide the adequate infrastructure, human resources, and capital needed to respond to the long-term needs of Syrians settled in the region. These not only encompass securing basic necessities such as food, water, adequate shelter, and medical resources, but also investing in the future social, financial, physical, and mental well-being of displaced populations.
Yet, any long-term solution will be contingent upon serious changes in the political and socioeconomic context, ones that hold the current Syrian regime accountable for its long series of crimes against humanity and provide an opportunity for Syrians to rebuild a country where freedom and democracy are inalienable rights.
Salma Daoudi is a researcher and Dphil candidate in International Relations at the University of Oxford, specializing in international security and global health, with a regional focus on the Middle East and North Africa.