Trapped in a Deadly Nexus: Cholera Outbreak and Water Crisis Amplify Syria’s Humanitarian Crisis by Hiba Mohammad

Originally published:

The Water Crisis in Syria

After enduring more than a decade of unyielding conflict, Syria is now mired in poverty and sickness. Millions of Syrians are facing life-threatening insecurity due to widespread impoverishment, prolonged famine, and reduced access to basic necessities. In 2023, Syrian people continue to face dire circumstances, with over 15.3 million individuals in need of urgent humanitarian assistance due to widespread fuel and food shortages, and over 90 percent of the population currently living below the poverty line.

Tragically, the unfortunate reality is that clean drinking water is a scarce commodity, and has been influenced by various factors, including politicization.

Amidst the turmoil of the Syrian conflict, there have been reports of water being used as a tool of control or harm by various parties in Syria [1]. In 2012, Tishreen Dam was taken over by Syrian opposition forces [2]. In 2014, the opposition gained control of Ain Al-Fijah spring, which allowed them to have some influence in negotiations with the Syrian Government by controlling the water supply of Damascus [3].  Later in 2017, the Syrian Democratic Forces (SDF) and Kurdish militia, with the assistance of the US military, successfully regained control of the Tabqa dam from ISIS. Unfortunately, the dam sustained significant damage during the conflict and required suspension. Reports conducted in June 2022 revealed three percent of populated communities have reported inadequate access to their primary water source within the past 30 days. Based on population estimates, a total of over 850,000 individuals were limited to accessing their primary water source for a mere 1-2 days during the month of June. In the northwestern region of Syria, a significant proportion of individuals residing in camps and communities depend on water trucking as their primary source of water, with approximately 73% and 63% respectively [4].  There have been some challenges with the water system in northern Aleppo, specifically with the Al-Khafsa water station and the Ein El-Bayda water pumping station. These challenges have impacted the water supply for approximately 184,000 people in the Al-Bab sub-district.

As a conclusion, the water systems have suffered significant damage, leaving millions without access to clean water for their basic needs.

Cholera, a notorious disease of poverty

Cholera, a disease that is commonly associated with impoverished communities, flourishes in countries affected by conflict where access to safe drinking water and proper sanitation is uncertain. Experience the devastating effects of cholera in densely populated urban and peri-urban areas where proper sewage and water treatment facilities are lacking. The targeting of Water, Sanitation, and Hygiene (WASH) infrastructure has the potential to exacerbate the prevalence of waterborne infections [5].

Cholera makes a comeback in Syria as earthquakes impede efforts to contain the outbreak.

Situation in Syria

Syria is currently facing a challenging situation as it navigates the impact of a prolonged economic downturn since 2019 and the aftermath of COVID-19 pandemic, compounded by the emergence of another debilitating disease.

According to the statistical records of the Ministry of Health, there have been instances of cholera outbreaks on an annual basis, with data available dating back to 1970. To provide an example, it can be noted that the number of laboratories confirmed incidents experienced a significant increase from 2816 in 1970 to 8523 in 1977. One of the more challenging years in terms of disease control was 1993, with a significant number of infections reported across all governorates. Fortunately, the outbreaks came to an end in 1997, thanks to the country’s efforts to enhance its water, sanitation, and health infrastructure [6].There was a brief increase in the number of cholera cases registered in the northeastern governorates of Deir Ezzor and Raqqa in 2008-2009. However, there have been no reported cases of the disease in the past thirteen years [7]. Likewise, there was an increase in the number of cases observed towards the end of 2015, as 936 suspected cases and 8 fatalities between the dates of August 25th and September 10th, 2022 [8].

Amidst the persisting conflict, the Syrian health authority declared a Cholera epidemic on September 10th, 2022, which has impacted several governorates across the country. The quantity of presumed instances has exceeded 10,000 [9].

The original cholera epidemic was concentrated in Deir Ezzor, Aleppo, Raqqa, and Hassakeh. However, the war’s water and sanitation infrastructure catastrophe are spreading cholera to many other governorates. This has forced many to use unsafe water, worsening the problem. The World Health Organization (WHO) issued a warning on October 5, 2022, indicating that cholera was experiencing a resurgence in various regions [10]. As of October 22, 2022. According to the Syrian Ministry of Health, the number of confirmed cases has reached 942, with 44 reported deaths [11].

Following the aftermath of the devastating seismic activity and the consequential collapse of vital infrastructure, unfortunately, the risk of cholera remains alarmingly high, while the resources to combat it are severely limited.

As of February 4th , 2023, the region of northeast Syria has reported approximately 148,000 cases of acute watery diarrhea and 32 fatalities subsequent to the declaration of a cholera outbreak by the Syrian Ministry of Health in early September 2022 [12]. Additionally, there have been 50,000 suspected cases and 21 deaths reported in northwest Syria as of February 25th, 2023. The actions taken by Turkish authorities with regards to the Allouk pumping station have had an impact on the current efforts to address the cholera outbreak, leaving over 460,000 individuals affected by the politicization of WASH infrastructure, resulting in disruptions to their water supply [13].

The present surge in concern can be attributed to various factors, primarily including the growing scarcity of water and the heightened reliance on hazardous water sources.

Reason on Cholera Outbreak in Syria

Main Causes of Cholera Outbreak in Syria. Prepared by the author

No Energy, No Water

The electricity sector in Syria, which is owned by the state, was in a state of vulnerability even prior to the onset of the crisis. The demand for electricity was experiencing a consistent and rapid increase, surpassing the growth rate of generation capacity. This resulted in power outages and the need for load shedding. Notwithstanding the aforementioned challenges, access to electricity stood at 93% in the year 2010, compared to 89.1% in 2020 [14].  In 2021, the priority ranking of surveyed households indicated that access to electricity had risen to the third-highest position [15].

Beginning in 2020, a situation that was already serious was exacerbated by the occurrence of severe electrical shortages. There has been a further 40% decrease in public output, resulting in a current level that is approximately one-third of the levels observed prior to the crisis. The per capita drinking water shares in urban areas have decreased to 64% of the levels observed prior to the crisis, whereas in rural areas, the shares have declined to 38%. Rural areas exhibit a significant deficit in access to water supply, with a per capita consumption of merely 30 litres per day [16].

The limited availability of energy sources has had an impact on the accessibility of water for Syrians, which is concerning given the significant decrease in power generation capacity in the region, up to 70%. The three primary sources of potable water in Syria, namely groundwater, rivers, and springs, are reliant on electrically powered water pumps. A minimum of five consecutive hours of uninterrupted electricity is necessary for wells in optimal condition to effectively pump water. Additionally, an additional two hours are required to adequately fill the tanks within residential properties.

Drought Spells and Low Water Levels

The levels of groundwater and the Euphrates River were significantly impacted by the drought experienced in 2021. Although there was a modest improvement at the start of 2022, water levels are progressively decreasing, resulting in a situation of water scarcity and exacerbating the strain on already limited resources, regardless of their quality and degree of contamination.

Given the dwindling levels of the Euphrates River, the national water infrastructure of Syria has been destroyed, leaving the vulnerable population in a precarious situation exacerbated by drought-like conditions. Due to limited access to safe water sources, many people are forced to resort to unsafe options. This could result in the spread of dangerous water-borne illnesses, especially among young children.   As a result of the insufficient supply, the indigenous populace is left with no alternative but to depend on unsafe resources such as privately owned trucks [17] .

Unsafe Water Supply: “No Other Choice!”

In the past decade, the country has experienced a reduction of up to 40% in its drinking water supply. Approximately 60% of evaluated communities in the north easter region of Syria have reported an unpleasant taste of water, while 22% of communities have expressed the belief that water consumption is causing illness. The proportion of communities reported the utilization of techniques to enhance the safety of water rose from 10% to 20% during the period spanning from September to November. This trend may suggest a heightened consciousness among the populace regarding the prevention of waterborne illnesses [18].

As a result, many Syrians are forced to turn to untreated water sources, which can be a breeding ground for a variety of water-borne illnesses. The previous cholera outbreak in Syria in 2009 suggests that the outbreak may have been caused by contamination of the Euphrates River and crops [19]. The provision of water, sanitation, and hygiene services and facilities has had a significant impact on the safe and consistent accessibility of approximately 14.6 million individuals to safe water, along with other WASH services. Additionally, an estimated 7.6 million individuals are currently experiencing acute need for WASH services.  The recent earthquake has only added to the already existing insecurities faced by many families. Overnight, hundreds of families lost their homes, belongings, and sources of income. The damage caused to the already fragile civilian and public infrastructure has been significant.

Furthermore, nearly half of the sewerage systems are inoperative, resulting in 70% of the sewage being discharged without undergoing any treatment.  Additionally, according to reports, the disposal of sewage into the Euphrates River, which serves as the primary water source for the Northeastern region, could potentially increase the vulnerability of the already malnourished population to waterborne illnesses such as Cholera. Moreover, 80% of the assessed communities in the northeastern region lacked a sewage system, and 65% reported that not all households had access to sufficient water [18].  According to a recent study on the Euphrates River waters, it was found that there were 178 bacterial pathogens present. This was attributed to pollution caused by the receding water levels [20].

The outbreak is linked to drinking dirty water from the Euphrates River and using it for agricultural irrigation.


Cholera has been known to resurface after periods of being less prevalent. The cholera outbreak in Syria was influenced by several factors, including challenges with the health system, water and sanitation infrastructure, education and hygiene, governance, and socioeconomic conditions. It would be beneficial to explore a diverse range of interventions, beyond solely medical approaches, to comprehensively tackle this outbreak. It is important to prioritize access to vaccination and safe drinking water and sanitation to effectively manage the spread of the disease.

It may be advantageous for NGOs to explore the development of community engagement plans that carefully consider the current crisis and difficult circumstances, with an emphasis on engaging families at the grassroots level. In situations where government presence may be limited, it is crucial to establish a well-coordinated response mechanism to address any potential gaps in services and ensure their dependability.


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