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Syria’s Polio Epidemic: The Suppressed Truth

Syria-MAP-022014
Mike King

Yet the Syrian government claims that the polio in Deir Ezzor was brought into the country by an opposition fighter from Pakistan. The strain of polio now spreading is indeed related to strains circulating in Pakistan, but also to those detected in Cairo in late 2012 and in Israel in early 2013. So it is at least as likely that Syrians who previously fled the war for Egypt have brought polio back themselves. In Israel, where the polio virus has now been found in 140 sewers and in stools from forty-two people, not a single child has been affected, due to excellent vaccination coverage.4

Despite its claims to have set up an effective early-warning system in September 2012, the Syrian government failed to detect the polio outbreak in its early stages in the spring of 2013. The opportunity to contain the virus within a single region and prevent its spread to other parts of Syria was thus lost. Yet a recent December 2013 article jointly published by Ministry of Health and WHO officials stated that the early-warning system

is established and functional. It has succeeded so far in mitigating the consequences of many outbreaks, responding to a nation-wide measles outbreak, a typhoid outbreak in Deir ALZour, and the present polio outbreak.5

In fact, the government’s warning system not only missed the first case, it missed the first two dozen. It’s still missing them: there have been at least forty-six new cases since the last “official” case was documented by the Syrian government and WHO in October.

In the spring of 2013, rising concern over the risk of diseases with epidemic potential led the opposition group ACU to develop its own parallel early-warning system. Supported by the American CDC, it trained doctors inside Syria to detect typhoid, polio, and other infectious diseases. By July it had established an effective surveillance system across seven opposition-held governorates, and was well positioned to bring the polio outbreak into sharp focus with the hot cluster it found in Mayadin in early October. But major discrepancies exist between the findings of the ACU and the official figures circulated by the Syrian health ministry and WHO, which insist that the epidemic has been brought under control.

According to the Ministry of Health and WHO, there are still only seventeen confirmed cases of polio—fifteen from Deir Ezzor, one in Aleppo, and one in besieged Douma, a suburb of Damascus. But the Turkish Ministry of Health, using samples provided by the ACU, has separately confirmed sixteen positive cases, at least thirteen of which are in addition to the official figure, the most recent on December 5 in Ar-Raqqa, and sixty-one additional cases—all outside government-controlled territory. These additional cases have not been laboratory-tested but meet the classical criteria for polio as defined by the CDC, with seven new cases reported in the first two weeks of 2014.

Yet the official government line—now adopted by WHO and the UN— is that Syria remained polio-free until October, and that no new cases of polio have been found since October 8. WHO has gone further, standing by its figures and reporting to The New York Times that polio is under control. These are the same WHO and Ministry of Health that have made no attempt to verify the cases confirmed through the Turkish Ministry of Health.

Meanwhile, WHO, forced to toe the government line, cannot publicly acknowledge the Ministry of Health data, which I have seen, showing that a girl in Aleppo had contracted the virus in August, that the case in the Douma suburb of Damascus happened in September, and that in addition to the acknowledged seventeen cases of polio, four more meet the clinical criteria.Worryingly, these same official bodies report 124 cases of “non-polio” acute flaccid paralysis, without providing proof of an alternative diagnosis.

My careful combining of the two databases—the ACU’s and that of WHO and the Syrian Ministry of Health—shows an absolute minimum of at least ninety-three cases of polio, of which at least thirty have been confirmed by laboratory tests.

Whatever the actual number is, when the first cases were confirmed by the CDC in October, this signaled the widespread transmission of polio across many parts of Syria. Moreover, the exodus of refugees caused by the war and particularly by Assad’s bombardment of civilians meant that a certain percentage of refugees already in neighboring countries must be carrying the virus.

Ironically, Syria’s children are now at greater risk than children in the three countries where polio is still endemic (Afghanistan, Pakistan, and Nigeria) because they lack the natural immunity that comes from exposure and because the spread of polio by respiratory means is aggravated by the crowded conditions under which millions now live.

To avert a polio epidemic, a surveillance system is required that can trace affected children and contacts more rapidly than the virus spreads, but the government’s sloppy surveillance and months of denial mean that it is now impossible to contain it. The government should have allowed access to contested areas to reach affected children. It should also have mounted a widespread water decontamination effort, as well as monitoring sewers nationwide the way Israel is successfully doing. The government’s response, supported by WHO, has been to mount a belated and poorly designed vaccination campaign. It claims without proof that 2.2 million children have received one dose of vaccine.

To reach all children, the best practice—and WHO’s and UNICEF’s international standard—is to conduct a door-to-door campaign. In late November, the Syrian government and the UN finally sent hundreds of thousands of vaccines to some contested areas. But while the UN claims that some of these vaccines have been delivered “door-to-door” in Deir Ezzor, doctors in the region report that the campaign has largely relied on people at the dwindling number of health centers, leaving it to parents to hear of the vaccination campaign and bring their children there. The UN also now acknowledges that it has missed 800,000 children who reside in “inaccessible areas,” including Aleppo, rural Idlib, and rural Damascus.

In some places, the government has not installed a “cold chain”—the linked refrigerated facilities needed to keep the oral vaccine frozen and viable. The oral vaccine requires multiple doses over several months, but according to the Qatari Red Crescent, which is monitoring the vaccination effort, the Syrian government is not keeping records to show which children have been vaccinated, where, and how many times, or which are still at high risk. Many Syrian government staff have been simply carrying vaccine around in plastic bags during the relatively warm fall. Some government health workers are reportedly charging $1 per head for what should be a free service, and vaccines have even shown up in private pharmacies.

Despite claims by both the Syrian government and WHO that the campaign has reached most children at risk, the government’s vaccination effort is focused on children in government-controlled areas, where hospitals are open and food, clean water, and fuel are available, while neglecting the children in the opposition-held areas where polio has actually broken out. In those areas, the government continues to attack civilians, hospitals, and schools.6

The officially reported numbers about children vaccinated have been as inconsistent and unreliable as the numbers about children stricken by polio. The joint Syrian government/WHO campaign ostensibly began on October 24, targeting 1.32 million Syrian children “at risk” for polio under age five.7 This figure has been heavily revised upward several times since then, as the government responds to growing evidence that the number of unvaccinated children is much higher, most recently on January 6. (There are nearly four million children under five in Syria.) On December 16, Syrian Minister of Health Saad al-Nayef said that “the biggest number of the vaccinated children was in the eastern city of Deir Ezzor, reaching nearly 294,000 children while 269,000 were vaccinated in Hama and 247,000 in al-Hasaka.”8 The UN has meanwhile cited even higher figures, stating, for example, that 307,105 children had been vaccinated in Deir Ezzor.

WHO has been heavily criticized for leaving Deir Ezzor out of a polio campaign in December 2012, apparently having been told by the government that the province was depopulated due to the conflict. The Syrian health minister denies as “baseless and untrue” a Reuters report that “Deir Ezzor was excluded from the vaccines,” while Elizabeth Hoff, head of WHO Syria, reiterated to me recently: “WHO within a sovereign country has to accept the government’s position.” It remains unclear whether the government lied to WHO, whether it informed them it had no interest in vaccinating Deir’s children or chlorinating its water, or whether it couldn’t convince SARC to deliver the vaccines after having shot several SARC workers in Deir city.

Meanwhile, the UN backs the regime’s claims with various press releases: “538,000 vaccines airlifted to Hassake,” reads one UNHCR report; “3.3 million children vaccinated against polio,” states another by UNICEF and WHO. But even the numbers cited by WHO and the regime are inconsistent and regularly changed.9

We are told nothing about the children already infected. The acute flaccid paralysis described in official accounts of polio sounds straightforward, but in fact, as I have found during fifteen years working in war-torn countries, polio is hard to recognize in real time. Most children with polio exhibit paralysis of just one leg, which may have begun weeks earlier during a cold or gastroenteritis along with symptoms such as fever, headache, sore throat, and myalgia. Yet colds, diarrhea, and fever are common, particularly in the conditions now prevailing in Syria. Flu causes headaches and myalgia all the time.

In December, I tracked down one of the few pediatricians in Deir Ezzor governorate, who said he had recently seen

a one-year-old, a boy displaced from al-Hasakeh. His mother took him to many clinics because he wasn’t crawling or moving his right leg any more. It happened after a cold, she said. Three months ago. Actually his whole right leg became paralyzed, but he was given the wrong diagnosis—of hip dysplasia. He wasn’t vaccinated—there aren’t vaccines, she said.

Appalling as polio is, 30 percent of children who suffer acute paralysis will recover completely within weeks or months, and another 30 percent will end up with only mild paralysis—if they receive appropriate treatment, effective physical therapy, and good nutrition to restore muscle function. All of these are rare in Syria today. Support by the victims’ families—for rehabilitation and to correct stigmatizing myths of infertility and affected intelligence—is essential. Sadly, it is common practice in Syria to give intramuscular injections—whether of antibiotics or pain relievers, for example—which can exacerbate or cause paralysis.

Infants and toddlers are more likely to suffer acute paralysis of limbs; older children are at greater risk of paralysis of the breathing muscles, so that without respiratory support the child will suffocate. Yet because the Syrian government has decimated the ranks of doctors, nurses, and physical therapists, and because it has deprived whole cities of food, paralyzed children have much less chance of making it through the acute stage, let alone of full recovery. Speaking to a doctor who had examined a thirteen-month-old girl from Spighan, I was told of weakness in her legs and chest, a weak cry, and a poor cough—signals of respiratory distress. When I asked what was being done for her, he replied: “There is no way to measure saturation, monitor respiration, or ventilate—no electricity for about a year now, let alone oxygen. Supplies stopped two years ago. All I could do was diagnose her.”

  1. 4

    “Wild-type Poliovirus 1 Transmission in Israel—What Is the Risk to the EU/EEA?” European Centre for Disease Prevention and Control. 

  2. 5

    Ghada Muhjazi et al., “An Early Warning and Response System for Syria,” The Lancet, December 21, 2013. 

  3. 6

    “Draft Press Statement on Aleppo Strikes Under Silence,” UN Security Council “What’s in Blue” Series, January 8, 2014. 

  4. 7

    Syrian Arab Republic Polio Situation Report No. 1, November 7, 2013. 

  5. 8

    “Minister: 2.177 Million Children Vacciated Against Polio” and WHO: Syria’s Response to Polio Virus Swift and Qualitative,” Syrian Arab News Agency, December 23, 2003, and January 5, 2014. 

  6. 9

    “Paralysis: How Political Deadlock Is Failing to Stop Polio in Syria,” Médecins Sans Frontières blog, December 11, 2013. 

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