One way to measure the horrific suffering of Syria’s increasingly violent war is through the experience of Syrian children. More than one million children are now refugees. At least 11,500 have been killed because of the armed conflict,1 well over half of these because of the direct bombing of schools, homes, and health centers, and roughly 1,500 have been executed, shot by snipers or tortured to death. At least 128 were killed in the chemical massacre in August.
In the midst of all this violence, it is easy to miss the health catastrophe that has also struck Syrian children, who must cope with war trauma, malnutrition, and stunted growth alongside collapsing sanitation and living conditions. Syria has become a cauldron of once-rare infectious diseases, with hundreds of cases of measles each month and outbreaks of typhoid, hepatitis, and dysentery. Tuberculosis, diphtheria, and whooping cough are all on the rise. Upward of 100,000 children are stigmatized by leishmaniasis, a hideous parasitic skin disease that flourishes in war. Many of these diseases have already traveled beyond Syria’s borders, carried by millions of refugees. Five million more children have been forced out of their homes but are still living within Syria, increasingly vulnerable to early marriage, trafficking, and recruitment as child soldiers.
And now polio is back. Since May, Syrian doctors and international public health agencies have documented more than ninety cases of polio in seven of Syria’s fourteen administrative districts, or governorates: Deir Ezzor, Aleppo, Idlib, Hama, Damascus, al-Hasakeh, and Ar-Raqqa. At an average age of just under two, most victims are—or used to be—literally toddlers. Few were fully vaccinated. None has had treatment to prevent paralysis from becoming permanent. All are from areas long opposed to the Assad regime, which reflects the political dimension of the outbreak. Not a single case has occurred in territory controlled by the government.
Once the most feared disease of the twentieth century, polio in most countries had long ago passed into the history books. Syria was no exception. Polio was eliminated there in 1995 following mandatory (and free) immunization introduced in 1964 after the Baath party took power.2 Yet wildtype 1 polio—the most vicious form of the disease—has been confirmed across much of Syria.
Ninety or so afflicted children may sound like a small number, but they are only a tiny manifestation of an enormous problem, since for each crippled child up to one thousand more are silently infected. Polio is so contagious that a single case is considered a public health emergency. Ninety cases could mean some 90,000 people infected, each a carrier invisibly spreading the disease to others for weeks on end.
This man-made outbreak is a consequence of the way that Syrian President Bashar al-Assad has chosen to fight the war—a war crime of truly epidemic proportions. Even before the uprising, in areas considered politically unsympathetic like Deir Ezzor, the government stopped maintaining sanitation and safe-water services, and began withholding routine immunizations for preventable childhood diseases. Once the war began, the government started ruthless attacks on civilians in opposition-held areas, forcing millions to seek refuge in filthy, crowded, and cold conditions. Compounding the problem are Assad’s ongoing attacks on doctors and the health care system, his besieging of cities, his obstruction of humanitarian aid, and his channeling of vaccines and other relief to pro-regime territory.
Sofie (not her real name), the first Syrian child known to have come down with polio, came from Spighan, a small town on the Euphrates River in the Mayadin district of Deir Ezzor. An unimmunized three-year-old, her initially unremarkable symptoms of fever and a cold were followed by acute flaccid paralysis, the sudden loss of muscle function, as the polio virus destroyed Sofie’s nerve cells. Untreated, polio has left her crippled, stigmatized, and shunned. Since then dozens more children in Deir Ezzor have succumbed. In August, cases started cropping up in other parts of the country: first in Aleppo, then in an opposition-held suburb of Damascus, Idlib, al-Hasakeh, and finally Raqqa in December.
Dr. Mohamed Wajih, the former head of the Aleppo Medical Council, described to me the government’s manipulation of the once-routine vaccine program:
Well before the revolution, the regime withheld vaccines from Deir Ezzor. In some liberated areas supplies to the health centers still existed but nurses stopped being paid, or the centers had no power to refrigerate the vaccines. For many nurses it was too dangerous to get to work.
Of the 1,919 health centers across the country before the war, 652 have been destroyed, shut down due to insecurity, or closed for lack of power, the vast majority in opposition-held areas. In the Aleppo governorate, vaccines stopped being delivered to rebel areas as violence broke out. In Aleppo city, the reach of vaccination parallels the “Death Path”—the few hundred yards separating government—from opposition-held areas. Doctors and others have told me of snipers in Aleppo deliberately shooting civilians in this corridor, including infants and children.
This politicizing of public health meant that many children born in 2010 or later could not commence or complete the routine course of polio vaccination required for effective protection. Of the roughly 1.8 million children born since the conflict began, more than half may be completely unvaccinated. WHO estimates that the vaccination rate has dropped from 83 percent of two-year-olds before the war to 52 percent in 2012.3 The Syrian Ministry of Health states that the vaccination rate has dropped from 99 percent pre-war to 68 percent in 2012. More than three million children across Syria may now be vulnerable.
The main UN agencies—WHO, UNHCR, UNICEF, and the World Food Program—that began deploying in Syria in early 2012 to mitigate the government-created humanitarian crisis are all forced to stay in Damascus city. Their current UN mandate requires that they respect the regime’s sovereignty, making their operations contingent upon government consent. The millions of dollars of food, medical aid, and other humanitarian supplies provided by UN-financed convoys are all controlled by the regime.
The UN’s current polio vaccination program—sponsored by UNICEF and delivered in UN-financed convoys and flights—is fully orchestrated by the Syrian government, and in opposition-held areas, it is dependent for administration on volunteers from the government-dominated Syrian Arab Red Crescent (SARC). SARC’s president, Abdul Rahman Attar, is closely tied to the government, and even has his own pharmaceutical company, which has influenced the preference given to regime territory in the administration of polio vaccines during these last three years.
It is notable that polio first appeared in Mayadin, a Sunni-dominated district in eastern Syria. This same district suffered a cholera outbreak in 2009. Four years of drought on top of four decades of dictatorship led to contaminated water, lack of water treatment, and ineffective sanitation. Showing its reluctance to help an area seen as hostile to the Baath regime in Damascus, the government denied that cholera had broken out, despite three thousand cases and the deaths of three children. It still denies that such an outbreak took place. Doctors and pharmacists told me of colleagues imprisoned for calling the disease cholera and for raising public awareness of it.
Four years later, raw sewage in Mayadin is still pumped into the Euphrates River a few hundred yards above the pump that provides water for the village, but chlorine to decontaminate the river water has been lacking since 2012. Assad’s method of fighting the war has generated the perfect conditions for polio: the severe malnutrition we see now in many opposition-held areas, on top of appalling living conditions, makes children more vulnerable to succumbing both to polio and to the risk of permanent paralysis.
Since 1988, the Global Polio Eradication Initiative has brought together national governments, WHO, Rotary International, the US Centers for Diseases Control and Prevention (CDC), and other groups. In 2007, Bill Gates joined, contributing hundreds of millions of dollars in the hope of eliminating polio the same way that smallpox was in 1977. But smallpox was different. It was easy to spot: the infected have a glaringly obvious rash. It is a huge virus covered by a viral envelope, an outer layer that is easily destroyed with soap. Only one shot of vaccine provided immunity.
Polio, by contrast, is a virus so small it slips even through surgical masks. The lack of an envelope renders the virus immune to most antiviral agents including soap, acid, alcohol, and freezing. It survives on surfaces for hours and in raw sewage for months. Flies spread it with their legs. Heavy doses of chlorine are needed to kill it in contaminated water. Effective vaccination requires several rounds. And it is mostly carried invisibly by children without polio symptoms—who are infected not only from drinking or eating something contaminated by feces, but also by coughing, sneezing, and kissing, particularly in crowded conditions. Children who do become paralyzed have already had the virus for one to three weeks, and as noted, each infected child means up to a thousand others are also silently spreading the infection. It is no wonder that after twenty-five years of eradication efforts polio persists, and in the last two years has gained ground.
Despite the threat posed by polio to millions of Syrians, the Syrian government has refused to take responsibility for controlling it. For months the Syrian Ministry of Health denied that polio had even broken out. In the first week of October, after widespread reports of polio in Deir Ezzor, a group of Syrian doctors independent from the government took three samples from a “hot cluster” of twenty-two acutely paralytic children there. The doctors were from the Assistance Coordination Unit (ACU), an organization set up in 2012 by the main alliance of opposition groups, the Syrian National Coalition, to coordinate humanitarian efforts in opposition-held territory.
Since the Ministry of Health had already refused to investigate this cluster and the analysis provided by the National Polio Laboratory in Damascus was in doubt, the ACU was advised by the US CDC to take the samples to a specific hospital in Turkey where polio analysis could be done. Even then, WHO officials ordered the Turkish hospital not to accept the samples, because they had been removed from the jurisdiction of WHO in Syria. Turkey’s Ministry of Health immediately took the initiative to analyze the samples itself, with the help of the CDC. As international scrutiny grew, the Syrian Ministry of Health accepted fourteen separate samples at the national lab, but then claimed the samples had been contaminated and maintained that the paralyzed children in Deir Ezzor had a rare neurological disorder.
Only after October 17, when the CDC confirmed that all three samples had tested positive for polio, did the Syrian health ministry make a swift about-face, “finding” polio after all in ten of its fourteen samples, which it had previously declared contaminated. WHO followed suit on October 29, finally declaring a polio outbreak. Even then, the health ministry made no attempt to trace the polio’s source, and it denied WHO permission to visit the affected areas of Deir Ezzor. WHO was thus barred from stool sampling, contact tracing, source identification, and survey of at-risk children, as well as the decontaminating of water and sewage or providing treatment of the affected children. By now, it is impossible to trace the source of the virus in Syria.
1 Oxford Research Group, Stolen Futures: The Hidden Toll of Child Casualties in Syria, November 2013. ↩
2 The last confirmed case was imported in 1999. VDVP (type 2) was isolated from one or more immundeficient persons in 2006. ↩
Oxford Research Group, Stolen Futures: The Hidden Toll of Child Casualties in Syria, November 2013. ↩
The last confirmed case was imported in 1999. VDVP (type 2) was isolated from one or more immundeficient persons in 2006. ↩