Syria’s Polio Epidemic: The Suppressed Truth

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.

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.”

On October 2, the UN Security Council unanimously adopted a statement by the UN president urging the protection of civilians, access to besieged communities, and humanitarian assistance across internal lines and international borders. However, the Syrian government continues to forbid the UN and its agencies to provide cross-border aid from Turkey, although this is by far the easiest and most efficient way to reach many of the 2.5 million children in most urgent need of food, water, and vaccination. The UN’s humanitarian chief, Valerie Amos, says that cross-border aid remains “a red line for the Syrian government.”

Given the serious questions about the government’s response to the polio outbreak, several nongovernmental organizations, guided by the ACU, banded together in November to form the Polio Task Force to meet the needs of the estimated 2.7 million children most at risk. The task force established a cold chain across seven governorates in northern Syria, trained more than six thousand health care workers, and raised awareness in at-risk communities.

But the ACU effort has been stymied by a lack of vaccines—neither Damascus, WHO, nor UNICEF would or could provide them. Doctors Without Borders–Holland tried to buy polio vaccines directly from a manufacturer, but UNICEF, acting on the Syrian government’s behalf, was forced to block it. Only in the last days of December was the Turkish government able to facilitate the provision of 2.5 million doses of vaccine—enough for one round—for use in Syria. A midwinter campaign for Syria’s children outside government-controlled areas began in early January.

Turkey vaccinates children who cross its border or live in refugee camps on its territory, but for children inside Syria, the Syrian government will not let WHO or UNICEF help the ACU. The UN agencies have chosen to maintain good relations with the government and access to government-controlled areas rather than demanding access to children at risk, and they fear expulsion if they do so. Unofficially, they freely acknowledge that there are unvaccinated children in many parts of Syria.

Although jihadists are increasingly dominant in many opposition-controlled areas, when I revisited the Turkish border in late December they were not blocking Syrians from conducting the polio campaign or leading medical convoys. The recent abduction of five international workers for Doctors Without Borders and the execution of an activist Syrian doctor, apparently by the al-Qaeda-linked ISIS, raise valid concerns about the safety of international and national aid workers. But the ACU’s cross-border campaign to vaccinate 2.7 million children has been facilitated by the Free Syrian Army and the Islamic Front, a group of rebel militias that this month began attacking the ISIS. Hundreds of ACU employees across northeast Syria are conducting a door-to-door campaign, coordinated with local councils, villages, and municipalities, which began on January 2. The ACU negotiated permission from all opposition groups, including the ISIS and al-Nusra. When one campaign leader heading a convoy of doctors and vaccines was arrested on January 1 at an ISIS checkpoint in Aleppo, he was quickly released. “Even ISIS recognizes the radical threat of polio, getting us and vaccines across borders where the WHO cannot,” I was told by Khaled Almilaji, who is coordinating the campaign led by the Polio Task Force.

Parallel with the Syrian government’s efforts, the UN and WHO have mounted an effort in the neighboring countries to try to mitigate the spread of polio beyond Syria’s borders. The plan is to vaccinate 22 million children over the next six to eight months.¹⁰

But by ignoring the epicenter of the epidemic, the UN facilitates Assad’s forced-displacement strategy, creating an incentive for civilians in opposition-held areas to flee abroad, where the chances of protecting their children from both bombs and polio are greater. As asylum seekers and smuggled migrants spread across the region, they put other Middle Eastern countries and Europe at risk of polio. The flurry of international humanitarian activity away from the epicenter of the polio outbreak diverts attention from Assad’s other ongoing atrocities.

What would an effective response to the outbreak of polio in Syria look like?

First, vaccination is a critical component, if the substantial deficiencies in the government’s program are rectified, and the ACU is fully supported. Starting vaccination at birth is essential.

Second, adequate nutrition is urgently required both for effective uptake of the vaccine as well as to protect vulnerable children from succumbing to polio. Both the ACU and the Ministry of Health report that 40 percent of children afflicted by polio paralysis had been partially or completely vaccinated. This means either that the vaccine was not viable when administered or that vaccination cannot protect starving children. An effective response to polio has to include a vast increase in the quantity and quality of food delivered to all areas in need regardless of the military force controlling the local population, including besieged areas.

Third, clean water is essential. According to a UN study, 4.4 million Syrians lack safe and sufficient water for daily needs, and the situation has seriously worsened within the last month.¹¹ Containing polio—not to mention preventing a comeback of cholera—requires decontaminating water, treating sewage, and restoring sanitation. (Removing the piles of trash all over the country, currently excellent breeding grounds for flies and other vectors of disease, would help considerably.) Clinical surveillance must be supplemented by environmental surveillance so that polio can be detected before children succumb to it, which requires unimpeded access by public health experts.

Fourth, children with polio must be treated. Syrian doctors and physical therapists are not familiar with polio, so they must be supported. Beds, splints, ventilators, oxygen, and a constant electricity supply must be put in place. WHO does not help when it claims on its website that “the only effective treatment is vaccination” or that polio causes “permanent paralysis within hours.” Neither is true, and the effect is to write off stricken children.

Fifth, the overcrowding of living quarters that has facilitated the rapid spread of contagious diseases must be addressed. Cold makes the effects of polio worse—tents should be replaced with solid structures.

Sixth, we must face reality: these vast essential needs will not be met by the Syrian government. And they will not be met if all international assistance must be channeled through Damascus. WHO, UNICEF, and other international agencies must be free to launch cross-border operations. But that will happen only if ordered by the UN Security Council. The current presidential statement only “urges” such cooperation—the most that Russia would allow, and so far not enough to convince Syria to cooperate. A UNSC resolution mandating cross-border aid is required.

Finally, the international community should stop pretending that mere vaccination is the answer. Nor should it accept the Syrian government’s efforts to pretend to be doing something to address the humanitarian needs of civilians in opposition-held areas while continuing its deliberate strategy—which amounts to a war crime—of making life as miserable as possible for the people living there. Rather than diverting attention from the regime’s war on civilians, the global threat posed by this polio epidemic provides the imperative for ending it.

—January 20, 2014