Disruption to water supply and waterborne communicable diseases in northeast Syria: a spatiotemporal analysis

Abstract

Background In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates. Methods We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence. Results The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p < 0.001), but downwards trends for acute jaundice syndrome, suspected typhoid fever and acute bloody diarrhoea. For the major disruption of the Alouk water plant, an interrupted time series analysis did not find a strong correlation between the disruption and changes in disease incidence in the weeks following the incident, but long-term increases in WBD were observed. Conclusions While no strong immediate correlation could be established between disruptions to WASH and WBDs in northeast Syria, further research is essential to explore the impact of conflict-associated damage to civil infrastructure including WASH. This is vital though challenging given confounding factors which affect both WASH and WBDs in contexts like northeast Syria. As such, research which includes exploration of mitigation after damage to WASH is essential to improve understanding of impacts on quantity and quality of WASH. More granular research which explores the origin of cases of WBDs and how such communities are affected by challenges to WASH is needed. One step towards research on this, is the implementation of adequate reporting mechanisms for real time tracking of the WASH attacks, damages, direct effects, and likely impact in conjunction with environmental and public health bodies and surveillance systems.

Public Health Implications of Cholera- a Water Sanitation and Hygiene (WASH) Related Infectious Disease in the Era of Climate Change: The Nigeria Experience

“…A decline in the practice of routine environmental sanitation and hygiene as reported by a preponderance of respondents was hardly surprising given that Nigerian rural areas have been reported to have one of the poorest accessibilities to clean water; such deficiency invariably impacts negatively on sanitary and hygienic behaviours leading to adverse consequences such as the spread of infectious diseases [8,44]. Inadequate availability of safe water has been linked to default in observing other WASH practices such as hand washing, as people will tend to economize the available water or make use of contaminated water [46,47].…”

Water and war: The effect of functioning chlorinated water stations in reducing waterborne diseases during conflict in northwest Syria, 2017–2021

“…Many districts had inconsistency in the number of water stations that were functioning or chlorinated, including Afrin, Al Ma’ra, Ariha, and Jebel Saman. This was due both to water infrastructures being destroyed during bombing and airstrikes and the challenges of managing civil infrastructure in humanitarian emergencies [ 15 , 18 ]. We were not able to identify which water stations were actively destroyed in the conflict, nor if districts with more dysfunctional water stations also faced more general violence, nor if other ecological factors could have influenced the findings.…”

“…In addition to expanding access to WASH practices, the UN and national governments should hold all parties involved in the conflict accountable for the targeting of water infrastructure, which violates international humanitarian law and causes significant morbidity and mortality [ 52 ]. Despite statements from the UN and the International Criminal Court addressing the targeting of civilian infrastructure as a potential violation of international humanitarian law, airstrikes on water sources by all parties have been a common occurrence throughout the war [ 15 , 18 ]. There are several opportunities for reparations and accountability: the UN could develop systems for documenting attacks on water sources (similar to the WHO SSA for attacks on healthcare) [ 53 , 54 ].…”

“…One study analyzed cross-sectional household survey data from southern Syria in 2016–2017 and found that while access to piped water dropped and households spent about 20% of their income on water, sanitation and hygiene access were protective against childhood diarrhea [ 17 ]. A recent literature review and analysis of EWARN (Early Warning Alert and Response Network) data on five waterborne diseases in Northeast Syria demonstrated the deliberate targeting of water infrastructure and the need for more granular analysis of such attacks and disease to assess the health impacts as their district-level analysis yielded concerning trends [ 15 , 18 ].…”

Water Energy Food Nexus to Tackle Climate Change in the Eastern Mediterranean

“…The food situation in Syria is equally precarious, with widespread food shortages and malnutrition, especially among children and women, who are vulnerable populations. Civil conflict has interrupted food production and delivery, reducing food supply and accessibility (Tabor et al, 2023). In addition, water shortages and decreased agricultural production have contributed to the country’s food insecurity and malnutrition crises.…”