The re-emergence of a disease all but eradicated in the developed world, polio, in Syria reflects cracks in the nation’s public health system.
It is often contended that in order to create, one must first destroy. This is the ideal upon which revolutions of the past have been built –that is, by bidding farewell to the present and ushering in a novel era. However, when you rip out the foundations of an existing society, the lives of the people who make up that society are invariably thrown into chaos. This trend has been observed throughout the course of history whether it was the Communist revolution in Russia or the French revolution of the 1700s. Landing in the present day, the civil war in Syria has been a major cause of rising tensions in the Middle East. With political giants, the army and militants engaged in a bloody struggle for power, the common people too, as a consequence, fight their own battles against hunger, poverty, disease and the multitude of other problems that follow in an unstable society.
This article examines the specific issue of polio re-emergence in Syria and surrounding countries as a result of these conflicts. Polio was one of the most widespread diseases in the 20th century and has especially plagued developing countries for a long time, as a grim reminder of their lagging growth. Eradicating polio in a country was, in a way, akin to lighting a beacon of hope that, in the not-so-distant future, both the country and the society will modernize, develop and transcend the barriers that inhibited its development in the past. The term re-emergence is used because polio is said to have been eradicated in Syria in 1999. However, fresh cases began popping up across the country in October of 2013. This multipartite conflict in Syria is particularly taxing in that it puts enormous strains on the local infrastructure. In an age when countries are making strides in healthcare by expanding access, why did polio decide to rear its ugly head again? What were the failures in the public health system and administration of Syria that lead to this outbreak? This article attempts to answer these questions, as well as elaborate on the impact that an issue of such enormity will have on a global scale.
Polio, the Silent Killer
It was Michael Underwood, a British physician, who analyzed and reported the first clinical case of polio in 1789. Subsequent infections were reported across Europe and the United States in the 19th century. However, as hygiene and sanitation improved in the 20th century, children were being exposed to this virus at an increasingly older age. As such, fewer children still possessed maternal immunity from birth and hence succumbed to the disease more easily. Consequently, poliomyelitis hit epidemic proportions in the 20th century.
The virus makes its way to the spinal cord where it causes a paralytic condition called poliomyelitis. Its primary targets are children and those who get afflicted often end up with debilitating deformities in their lower limbs. The disease in its early stage displays very general non-specific symptoms such as a sore throat, fever, vomiting, diarrhea and a host of other flu-like symptoms. Some people who contract the virus may simply be carriers and display no symptoms at all. Eventually, the viral particles reach other parts of the body, including the central nervous system (CNS), through the bloodstream. 0.5% of cases result in irreversible paralysis and this can happen within hours of infection of the CNS. Around 5-10% of these cases result in death due to paralysis of the breathing muscles. In nearly 2% of cases, a non-paralytic form of meningitis can also occur, resulting in stiffness of the neck, back and lower limbs.
What makes viral infections unique is that, unlike other infections of bacterial or fungal origin, they use a Trojan horse-like system to invade cells. They modify host DNA with their genetic material such that the host cells start to act as factories to produce these viral particles. Once enough of them have been synthesized, the host cell is burst open by a process called lysis and the new viral particles spread out to infect other cells.
By infecting the gastrointestinal tract, the polio virus (PV) is present in the feces of a viral carrier. Its main mode of transmission is through food and water contaminated with infected feces. This partly explains its high incidence in underdeveloped and developing countries. Poor infrastructure, leading to a host of unsanitary practises, facilitated transmission of PV in these countries.
While a cure for this disease does not exist, there are vaccines available, and through their utilization, the world has taken giant strides in eliminating polio from the face of the planet. The first vaccine for polio was developed by Jonas Salk in the USA in 1955. This was called the inactivated polio vaccine (IPV). In 1963, a second form of the vaccine called the OPV (oral polio virus) was developed. Unlike the IPV which comprises of the killed virus, the OPV is a live modified virus.
OPV has several advantages that made it the preferred form of vaccine endorsed by the WHO during its eradication campaigns. It could be administered orally and was also much cheaper to produce. One of the main advantages, however, is that the live vaccine virus can replicate in the intestines and can be excreted through feces. Consequently, in countries with poor hygiene and sanitation, this vaccine virus can spread to individuals in close contact essentially vaccinating them too in a process called passive immunization. This is the advantage of having a live virus. One minor disadvantage is that there is a 1 in 2.7 million chance that the vaccine virus will mutate to form a live infectious strain of the disease. On the whole, however, the benefits far outweigh the risks.
One of the most important steps taken in this endeavour was the establishment of the Global Polio Eradicative Initiative (GPEI) in 1988. Its goal was to eradicate polio completely through combined collaborative efforts of the WHO, UNICEF, CDC, Rotary International and several national governments. They were also aided by many private investors such as the Bill and Melinda Gates Foundation.
Since 1988, the number of cases of Polio in the world have been brought down by 99%. Afghanistan, Pakistan and Nigeria are said to be the only three countries in the world where endemic strains of the virus still exist. Eradication in these countries has been especially challenging due to areas that remain inaccessible as a result of political unrest and violence. Even those countries that have reported re-emergence trace the virus back to one of these three remaining endemic strains as a result of cross-border transmission.
In order to analyze the impact of this re-emergence, it is first important to understand the outset of the civil war in Syria. Since 1963, the country has been in a state of emergency and the citizens have had their constitutional rights revoked. The situation has continued to persist under the rule of President Hafez al-Assad all through 1970-2000 and under that of his son Bashar al-Assad (2000-present).
The growing frustration among the general Syrian population reached a tipping point when the Assad government opened fire on Syrian protestors in March 2011 in the city of Deraa. Subsequent acts of violence only hardened the resolve of the demonstrators who now demanded Assad’s resignation. Consequently, rebel groups and political groups across the land began an uprising, the former engaging in a direct armed struggle.
In the meantime, radical Islamist groups in the region have geared up to hijack this movement for democracy and use it to create an Islamic state in Syria. Some jihadist groups such as the infamous ISIS wish to go as far as establishing a pan Islamic caliphate. This struggle between the multiple competing groups for power has led to the disintegration of a state of order in large regions of the country.
Descent in Chaos
Before the crisis began in Syria, the country had been experiencing a period of improvement in its healthcare. Significant developments in infrastructure and improved access to rural areas under the Syrian decentralized healthcare system greatly reduced infant mortality, maternal mortality and also the spread of communicable diseases from 1970 to 2009. This period also saw a sharp rise in life expectancy by almost 18 years.
However the situation took a turn for the worse as the clouds of war gathered. Clashes between the rebels and the government has led to the death of at least 150 000 people, with shellfire, airstrikes and guns being the major cause of these deaths. Crippling blows have been dealt to the country’s infrastructure as nearly 4.4 million civilians have been driven from their homes. Almost 1.2 million of them have fled the country seeking refuge in the neighbouring regions of Turkey, Lebanon and Jordan. Every day is a new struggle as the Syrian civilians fight to stay alive amidst overcrowded, rapidly deteriorating conditions. Their access to basic necessities such as food, clean water and proper sanitation is heavily restricted. Buildings such as homes and hospitals have been decimated by airstrikes in rebel-held areas. The civilians in these regions –children, women as well as elderly people – are being killed indiscriminately. The government has gone so far as to use chemical weapons against the civilians. One doctor from Aleppo said, “The government’s polio control strategy for children is to kill them before they can get polio.”
In addition to the severe failures of infrastructure, further deterioration of the system occurred when doctors and health workers started fleeing the country in large numbers. In 2012, the Assad regime imposed sanctions on treating rebel patients in hospitals and any doctor who disobeyed this rule was branded a terrorist. Punishment included severe torture, sometimes leading to death. Targeted attacks have since been carried out against paramedics, ambulances and pharmacies as well. Besides destroying what little they had left of their health facilities, the Syrian government managed to spurn most of the local doctors away. Nearly 160 doctors are said to have been killed or assassinated for doing their jobs and almost 160 000 more have fled the country and are in hiding.
With an acute shortage of medical staff, hospitals and medicines, providing medical care to the ever-increasing victims of war has never been more challenging. For people with chronic diseases such as cancer, arthritis and heart problems, treatment is a thing of the past. Despite their dire situation, these individuals are left to wait and watch as treatment of people with life-threatening injuries takes precedence.
The assault on the health system has crippled Syria to a point where complete recovery in the near future is a questionable objective. The conditions described have made Syria a fertile breeding ground for numerous infectious diseases, one of the most prevalent of which is Polio.
To Cripple a Generation
As a result of free vaccines mandated in 1964, polio was eradicated in Syria in the year 1999. However, due to reasons mentioned earlier, fresh cases have been reported in October of 2013. The first victim of this outbreak was a three year old Syrian child from the region of Deir Ez Zor. Unimmunized and untreated, she has now fallen prey to a life of permanent paralysis. Deir Ez Zor is one of the rebel-held areas vehemently contested by the government.
The Assad regime has withheld supplies including vaccines to all rebel-held areas. Constant clashes have resulted in power outages, making it impossible to maintain a cold chain storage facility to protect vaccines from the heat. Consequently, Polio immunization rates have fallen from 91% in 2010 to 68% in 2012. Vaccination in rebel-held areas is said to be much lower. While WHO reports have estimated up to 37 cases as of March 2014, other sources including many Syrian doctors place the number above 100 in the region. The WHO claims that if left uncontrolled, this epidemic could spiral into nearly 200 000 cases within just 10 years. The impact of this epidemic on the daily lives of people is accurately summed up by the words of Dr.Basel al Khader: “It’s worse than shelling because it’s a silent killer. It’s not like an aeroplane overhead or an explosion you can avoid. It comes from the water.”
The viral strain circulating in Syria is speculated to have arrived from Pakistan, one of the only three countries in the world besides Afghanistan and Nigeria where polio is endemic. Further evidence comes from the fact that in December of 2012, polio virus of Pakistani origins was found in the sewers of Cairo.With the immigration of foreigners from around the world joining the rebellion and militant groups, cross-border transmission is a possibility that cannot be dismissed. This outbreak of Polio has far-reaching consequences not just for Syria, but for the entire Middle East. From the viewpoint of a country in which the existence of its very borders is a matter of speculation, the question arises; where do we start in order to control this spread?
In recent attacks directed by ISIS, much of the border between Syria and Iraq has been rendered defunct. Additionally, each passing day brings more and more refugees into neighbouring countries. This allows the virus ample opportunity to take root and germinate into anther outbreak in another nation. As long as there are countries that still have polio, the potential of seeing a worldwide re-emergence of the disease cannot be dismissed.
Eradicating polio in the three remaining regions where it is endemic continues to present itself as a herculean task. Radical Islamists in these countries campaign viciously against vaccines, making baseless claims that they cause infertility. Health workers and volunteers who try to contribute to vaccine promotion are killed every day. In the Taliban-controlled regions of Pakistan and Afghanistan, these campaigns are viewed as a cover for international espionage and anyone caught vaccinating the people is killed indiscriminately. It wasn’t until a couple of years ago that the Taliban officially pledged support for the Afghani anti-polio campaign under the condition that no foreign workers be involved. There is something to be said about the devastating impact of a disease if it can allow for the cooperation between a terrorist organization and government officials.
A Struggle for Revival
Once reports of an outbreak were received, many UN organizations responded by collaborating with the Syrian government and initiating a mass vaccination campaign. Its goal was to immunize nearly 23 million children across the country. Many Syrian groups, along with aid from the Turkish government, funded nearly 8000 volunteers to go door-to-door and vaccinate nearly 1.5 million children in the anti- regime regions of the country. Many of these doctors have also been killed in the conflict. Besides Syria, the WHO has also started similar campaigns in neighbouring countries such as Turkey and Iraq where samples of the virus have been found and reports of decline in vaccination rates have been reported.
Unfortunately, even these initiatives have been swayed from their fundamental goal to eliminate polio. While the WHO did respond to falling vaccination rates in 2011 and 2012, these responses were restricted to government-held and contested regions only. Many rebel-held areas such as Deir Ez Zor and Aleppo were left out in 2012, and consequently, the children in these regions – perhaps the most needing of help – were left to suffer. When questioned, the WHO responded by saying that their hands were tied in initiating a direct cross-border response. They had to work hand-in-hand with the Syrian government on this issue. It wasn’t until late 2013 that they started vaccinating children even in the anti-regime areas. The Syrian government too was very late in identifying this outbreak. Some sources say that the first case of polio was reported as early as April 2013, nearly 6 months prior to the date considered as the official start of the outbreak. Significant discrepancies have been found in the number of cases reported by various organizations as the WHO and Syrian government are accused of downplaying the extent of this outbreak and exaggerating their success.
The current efforts being made are not sufficient to control a multinational outbreak. With the civil war raging as intensely as ever and the arrival of new participants such as ISIS and other militant groups, access to areas where help is needed the most has become increasingly harder. The lack of a well- defined border has made it almost impossible to keep track of the number of people vaccinated. In addition to all of this, quality of life for the refugees is at an all-time low. A refugee from Damascus asked, “What is the point of vaccines if children don’t have basic drinking water or a proper sewage system?”
In order to effectively contain this epidemic, an efficient system of surveillance must be set up. The disease has to be tracked and its points of outbreak must be located faster than it can spread from one person to the next. This includes sampling sewers all over the nation not unlike the recently conducted Israeli campaign. Earnest international efforts should be taken to persuade the Syrian government to allow access to rebel-held territories. Eradication is out of the question without access to all civilians. Immunization cannot be achieved unless all the doses are given at appropriate intervals and this requires records to be maintained. Failure to adopt effective methods of controlling the outbreak may lead polio to become a global threat.
The irony lies in the fact that Syrian children who lack natural immunity to the disease are now at greater risk of contracting the poliomyelitis than children from Pakistan, Afghanistan and Nigeria where the disease is endemic. This manmade outbreak has demonstrated the extent to which war and conflict can destroy a nation and its people. That being said, the question remains; what more cause does the government need to end this conflict?
Vishwaksena Maram Reddy is a third year student studying Life Sciences at the University of Toronto.