Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011–2019

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Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011 –2019

AulaAbbaraâ,b,*,Omar Zakiehâ,DianaRayes^b,c,Simon M.Collin^d,Naser Almhawishê, Richard Sullivan^f,IbrahimAladhanê,MaiaTarnas^g,MollyWhalen-Browne^h,

Maryam Omarⁱ,AhmadTarakji^j,Nabil Karah^k

aImperialCollege,London,UK

bSyriaPublicHealthNetwork,UK

cJohnsHopkins,USA

dPublicHealthEngland,UK

eAssistanceCoordinationUnit,Turkey

fKing’sCollege,London,UK

gCommunityResearchInitiative,Charlestown,MA,USA

hUniversityofAlberta,Edmonton,Canada

iStBartholomew’sHospital,London,UK

jSyrianAmericanMedicalSociety,USA

kUniversityofUmea,Sweden

ARTICLE INFO

Articlehistory:

Received22February2021

Receivedinrevisedform12May2021 Accepted14May2021

Keywords:

WASH Conﬂict Diarrhea Jaundice Surveillance Syria

ABSTRACT

Objectives:Investigate theweaponization ofwaterduringtheSyrianconﬂictandthecorrelationof attacksonwater,sanitation,andhygiene(WASH)infrastructureinIdlibandAleppogovernorateswith trendsinwaterbornediseasesreportedbyEarlyWarningandResponsesurveillancesystems.

Methods:WereviewedliteratureanddatabasestoobtaininformationonattacksonWASHinAleppoand Idlibgovernoratesbetween2011and2019.Weplottedweeklytrendsinwaterbornediseasesfromtwo surveillancesystemsoperationalinAleppoandIdlibgovernoratesbetween2015andearly2020.

Results: The literature review noted several attacks on water and related infrastructure in both governorates,suggestingthatWASHinfrastructurewasweaponizedbystateandnon-stateactors.Most interferencewithWASHintheAleppogovernorateoccurredbefore2019andintheIdlibgovernoratein thesummerof2020.Otheracutediarrhearepresented>90%ofcasesofdiarrhea;childrenunder5years contributed50%ofcases.Therewassubstantialevidence(p<0.001)ofanoverallupwardtrendincases ofdiarrhealdisease.

Conclusions:ThoughnodirectcorrelationcanbedrawnbetweentheweaponizationofWASHandthe burden of waterborneinfections due tomultiple confounders,this research introducesimportant conceptsonattacksonWASHandtheirpotentialimpactsonwaterbornediseases.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc- nd/4.0/).

Introduction

AccordingtotheWorldEconomicForum(WEF),watercrises, alongsideweaponsofmassdestruction,failureofclimate-change mitigation, and extremeweatherevents, are someof themost severethreatstoglobalhealthsecurity(WEF,2019).In its2018

‘WorldHumanitarianData’report,theUnitedNationsOfficeforthe CoordinationofHumanitarianAffairs(UN-OCHA)notedthatwater accessplayedasignificantroleinconflictsinatleast45countries inoneoracombinationofthreeways:wateractingasthetriggerof conflict, water sources being intentional targetsof attack, and weaponizingwatersourcesthemselvesasatoolofconflict(UN- OCHA,2018).In Yemen, atleast 128attacksonwater systems, includingattacksagainstthemainwatersupplytoHodeida(Al- Hudaydah), jeopardizedaccess towaterfor millions acrossthe country(Habib,2020).Thishascontributedtooneoftheworst recentcholeraoutbreaks,withoveronemillioncasesreportedand

*Correspondingauthorat:DepartmentofInfection,ImperialCollege,StMary’s Hospital,PraedStreet,W21NY,UK.

E-mailaddress:a.abbara15@ic.ac.uk(A.Abbara).

https://doi.org/10.1016/j.ijid.2021.05.030

1201-9712/©2021TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

ContentslistsavailableatScienceDirect

International Journal of Infectious Diseases

j o u r n a l h o m ep a g e : w w w . e l s e v i e r . c o m / l o c a te / i j i d

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anincreaseinotherwaterbornediseases(Camachoetal.,2018;

Spiegeletal.,2019;UN,2018).Ithasalsoimpededresponsestothe COVID-19pandemic(Habib,2020).

Since thebeginning of the20thcentury, Syriahasfaced six majordroughtsand,likemanycountriesintheregion,investedin infrastructure suchasdams,irrigationsystems,and wastewater treatmentplants tosourceandcontrolthe movementofwater towardscommunitiesandagriculturalspaces(FanackWater,2019;

Gleick,2014).Beforetheconflict,Syriaexperiencedan extreme droughtfrom2006to2011,creatingpopulationdisplacementand a decline in water, sanitation, and hygiene (WASH) provision, particularlyinruralareas(Gleick,2014).Thisledsomecommen- tatorstoviewtheSyrianconflictasadirectresultofrisingtensions within communities resulting fromcropand economic failures causedbydrought(Abeletal.,2019;Hammer,2013).However,the origins and path of the conflict are more complex than this narrativewouldsuggest(Fouadetal.,2017).

Syria’s violent and protracted conﬂict, which began as a peacefuluprisingagainsttheGovernmentofSyria(GoS)in2011, has seriously exacerbated existing WASH challenges. Water in Syriahasbeenweaponizedbyallmajorpartiestocontrolorinﬂict damageonopponents,especiallycivilianpopulations(WorldBank Group,2017).Syriareliesonsevenmajorbasinstosourcewater from riversand lakes, suppliedbyannual precipitation(Fanack Water,2019).In2009,theFoodandAgricultureOrganizationofthe UN(FAO)counted166damsacrossSyria,mostsituatedinHoms andHamagovernorates.ThelargestistheTabqadam(alsocalled Thawradam),completedin1973nearRaqqahontheEuphrates.

ThisdamcreatedLakeAssad,Syria’slargestwaterreservoir,which suppliesmostofAleppo’sdrinkingwater(FAO,2008).Tishrindam (completed in1999)is ahydroelectricdam nearManbijonthe EuphratesRiver,bywhichelectricityissuppliedtotheRaqqaand Aleppogovernorates(Figure1)(Mroue,2012).

Dams and water sources in Syria have been captured by different forces during the conﬂict. In 2012, Syrian opposition

forcesseizedTishrinDamfromthegovernment(Mroue,2012).The BattleofTabqain2017sawtheSyrianDemocraticForces(SDF)and Kurdishmilitia,withUSmilitarysupport,recapturetheTabqadam fromtheIslamicStateof Iraqand Syria(ISIS); however,it was damagedtothepointofneedingtobesuspended.In2014,theFree Syrian Army’s (FSA) capture and control of the spring in Ain Al-Fijah,bywhich theycouldcontrolwaterentering Damascus, providedleveragefortheminnegotiationswiththeGoS(Reznick, 2016).

In additiontoinadvertentconﬂict-relatedpollution ofwater sources, ISIS has deliberately contaminated drinking water in governoratesincludingDeirez-Zor,Raqqa,andAleppotoexpand theircontrolover populations(CTED, 2017).Despitestatements fromtheUNaddressingthetargetingofcivilianinfrastructureasa potentialviolationofinternationalhumanitarianlaw,GoS-backed Russian airstrikes onwater sources have alsobeen a common occurrencethroughoutthewarand,by2016,itwasestimatedthat intentional attacks on water infrastructure had reduced the country’saccesstosafewaterby50%(Vidal,2016).

ThisweaponizationofwaterinSyriabyallpartiesintheconﬂict has exacerbated inadequate WASH for civilians inside Syria, increasingtheriskofwaterbornediseasesinaffectedpopulations.

Thispaperfocuses ontheAleppo and Idlibgovernoratesin the northwestofSyriaascasestudiestoexplorei.weaponizationof waterduringtheconﬂict,andii.trendsinwaterbornediseasesand potentialcorrelationwithattacksonWASHinfrastructure.

Methods

Attacksonandweaponizationofwatersourcesandsupplies

A literature reviewwas conducted toobtaininformation on attacksonwaterinfrastructureinAleppoandIdlibgovernoratesin Syria between 2011 and 2019. Keywords such as “water”,

“weaponization”, “waterborne disease”, “outbreak”, “conﬂict”,

Figure1.Mapofthe7majorwaterbasinsinSyria:Coastal,Orontes,BaradaandAwaj,Al-Yarmouk,Desert,Euphrates,andAl-Khabour(AdaptedfromFanackWater,2019).

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“Syria” were used in different combinations to search the databasesofPubMed,Ovid,Embase,GlobalHealth,HMICHealth ManagementInformationConsortium,Scopus,andGoogleScholar (seeAppendix).Non-peer-reviewedgreyliteraturewasidentiﬁed usingmultilateralorganizations’webportals,includingtheUnited Nations, World Health Organization (WHO), World Bank, UN- OCHA,ReliefWeb,andnon-governmentalorganizationsincluding ICRC MSF,SAMS, Savethe Children.Extracted information was used to compile a timeline of attacks on water infrastructure duringtheconﬂict.

Waterbornediseasesandsurveillancesystems

Dataoncasesofthediarrhoealdiseasewasextractedfromtwo surveillancesystemsoperationalinAleppoandIdlibgovernorates (Table 1). The Early Warning, Alert, and Response Networks (EWARN)weresetupinSyriabytheAssistanceCoordinationUnit, which formedpartof theSyrian NationalCoalition;it received supportfromWHOandfundingfromtheBillandMelindaGates Foundation. It works predominantly in non-government-con- trolled areas of Syria. EWARS (Early Warning and Response System) was establishedby theSyrian Ministryof Healthwith supportandfundingfromWHO.InIdlibandAleppogovernorates, EWARN covers most of the population in Idleb city and the surroundingcampswithsomecovertotheAleppogovernorate.As of thebeginningof2020,thehighestpopulationdensityinthe AleppogovernorateisinAleppocity,whichiscoveredbyEWARS.

Weekly reporting data included: total number of health facilities; the number of sentinel sites; the number of sites submittingweeklyreports;casesofdiarrhea,classiﬁedasacute bloodydiarrhea(ABD),acutewaterydiarrhea(AWD-indicativeof cholera), and other acute diarrhea (OAD); and acute jaundice syndrome(AJS-indicativeofinfectioushepatitis,e.g.,hepatitisA).

Wecombinedalltypesofdiarrheaintoatotaldiarrhealdisease case count for each week and plotted the weekly case count separatelyforAleppoandIdlibandthetwosurveillancesystems.

Wheredataweremissingforasingleweek,thenumberofcases wascalculatedasthemeanofcasesintheprecedingandfollowing week.Poissonregressionmodelsincludingsineandcosineterms forseasonalitywereﬁttedtotestforevidenttrendsinthetotal numberofcasesoverthewholestudyperiod.

Results

Atimelineofmajorattacksanddisruptionofwaterinfrastruc- tureinAleppoandIdlibgovernoratesbetween2011and2019is showninFigure2.

AttacksonWASHinfrastructureinAleppogovernorate

TheAleppogovernoratefirstenteredtheconflictinJuly2012 withfightingbetweenoppositionforcesandtheGoSanditsallies, Russia andHezbollah;violencecontinueduntilDecember2016, after asix-monthsiege thatbegan in July2016GoS closedthe

supply lines into Aleppo city. The ﬁrst attacks on water infrastructureaffectingAleppocityoccurredinSeptember2012 when its pipelinewas damaged, depriving 3 million peopleof water(WorldBankGroup,2017).In2012,oppositionforcesheld mostoftheeastandsouthwesternpartsofAleppocity;by2016,it wasestimatedthataround300,000peopleremainedinopposi- tion-heldEastAleppoand1.5millionremainedinGoSheldwest Aleppocity(Shaheen,2016).During2015,attacksbypartiesinthe conﬂict(GoS,JabhatAl-Nusra,Russia)affectedwaterqualityand supply. In December 2015, Russia bombed theal-Khafsa water treatmentfacilityineastAleppo city,cuttingoff pipedwaterto 3.5millionpeople(UNICEF,2015).Thetitfortatattacksonwater infrastructure in September 2016 affected running water for 2millionpeople(UNICEF,2016).GoSandRussianforcesdamaged Bab Al-Nayrab pumping station in east Aleppo city, depriving 250,000peopleofwater.Inretaliation,oppositionforcesswitched offSuleimanal-Halabistation;althoughlocatedineastAleppocity, itpumpswatertowestAleppocity,affecting1.5millionpeople.

Waterwassubsequentlyrestoredtothewesternpartsofthecityin November 2016 (World Bank Group, 2017). This left civilians reliantonnon-potablewater fromwellsordelivered in trucks, whichwasexpensiveandforwhichtheyhadtoqueueup,oftenfor extendedperiods(WorldBankGroup,2017).

AttacksonWASHinfrastructureinIdlibgovernorate

The Idlib governorate has seen constant violent clashes betweenGoSandoppositionforcessinceSeptember2012.During 2017,violencebetweenextremistgroupsAhrarAlShamandHay’at TahrirAl-Sham(HTS)eventuallyledtoHTSandoppositionforces takingcontrolofmostofthegovernoratebyJuly2018(Ali,2020).

Idlib governorate, mainly Idlib city, saw the most signiﬁcant violencebetweenAprilandAugust2019andafurtherescalation betweenDecember 2019andFebruary2020;this hasdisplaced around1millioncivilians(80%ofwhomarewomenandchildren) of the 4.17 million people in the area (Abbara et al., 2020b).

Signiﬁcant water infrastructure damage occurred in July 2019 when eight facilities in Al-Ma’ra district (three of which are supportedbytheUN),includingthecentralwaterstationinMaarat al-NumancityinsouthernIdlib,wereattackedbyGoS,depriving 250,000peopleintheareaofwater(Ortagus,2019).

Waterbornediseases

Weekly cases of diarrheal disease in Aleppo and Idlib governorates showed regular mid-year seasonal peaks corre- spondingtothelatesummermonths,morepronouncedin2017 and2019comparedto2015,2016,and2018(Figure3aandb).The seasonalitypatternwassuperimposedonanoverallupwardtrend ofcasesreportedbythetwosurveillancesystems(Figure3c).The upward trend was supported by solid evidence (p < 0.001) equivalent to approximately 12–16 additional cases per week, accordingtotheEWARNdata(2015–2020),and2–3casesperweek in EWARS data (2015–2019). Generally, there weremore cases

Table1

DifferencesbetweentheEWARNandEWARSsystemsinSyria.

System EarlyWarningandResponseSystem(EWARS) EarlyWarningandResponseNetwork(EWARN)

Administeredby WHOandSyrianMinistryofHealth AssistanceCoordinationUnit

Administrativebase Damascus,Syria Gaziantep,Turkey

Operatespredominantlyin Government-controlledareas Non-governmentcontrolledareas

Established September2012 June2013

Availabilityofdata January2014toDecember2019 January2014toApril2020

Overallcompleteness(weekswithdata) Aleppo98.1%(306/312) Aleppo98.8%(321/325)

Idlib95.8%(299/312) Idlib99.1%(322/325)

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reportedin Idlibthanin Aleppo governorate.Apeak ofaround 9,000casesoccurredinmid-2019inIdlibgovernorate,represent- ingaone-thirdincreaseonthetwopreviousyearsandarelatively largerincrease compared withtheAleppo governorate.Propor- tionsofABD,OAD,andAJSstratiﬁedbyage,<5yearsand5+years, are shown in Figure 3d. More than 90% of cases were OAD, apportionedapproximately50:50betweentheunderandover5 years age groups. Interestingly,the occurrence of ABDand AJS casesshowedagradualdeclineovertimealongwiththeabove- mentionedseasonalpeaks(Figure3e).

Discussion

TheweaponizationofwaterinIdlibandAleppogovernorates

AleppoandIdlibgovernoratesinSyriahaveexperiencedsome ofthemostextensiveviolenceinSyria’sprotractedconﬂict;water infrastructure has been attacked and contaminated as a war strategy by both the Syrian government and non-government forces.Asearlyas2012,Aleppocity’swaterpipelinewasdamaged, affectingwatersuppliesto3millionpeople.InIdlibgovernorate, themostextensiveattacksoccurredinsummer2019when8water facilitieswerebombedbyGoS.WASHcontinuestobeaffectedin bothgovernoratesbutparticularlyintheIdlibgovernorate,which hasseenarecent,furtherescalationofviolence,leavinghundreds of thousands in northwest Syria without adequate facilities (Abbaraetal.,2020b).ThisoccursatatimewhentheCOVID-19 pandemic in Syria is ongoing, leaving the population, mainly internallydisplacedfamilies,withinadequatefacilitiestoprotect themselves(Abbaraetal.,2020a).

In general, data reported by EWARN and EWARS were incompatible, especiallyinIdlibgovernorate,mostlikelydueto differentpopulationaccess.However,bothsystemshaveshowna trendofrecurringlate-summersurgesalongwithagradualyear- on-yearincreaseinreporteddiarrhealinfections.Theseasonality

ofwaterbornediseasesisinlinewithseveralstudiesfromother developingcountries(Kulinkinaetal.,2016).ForbothEWARNand EWARS,therewaslikelyalearningcurveasdifferentfacilitiesfed intothe reportingsystems, and healthcare workersreportthat reportingaccuracymayfallwhenattacksareattheirgreatest.This isalsoreﬂectedindatacompletion,whichincreasedfromwhen EWARNandEWARSwereﬁrstimplementedtonearing98–100%

morerecently.

Trendsof waterborne diseasesin warzonesare likely tobe affected by various factors, including combat and destruction events, population movements, undisclosed contamination of water(Schillingeretal.,2020). Inconsistencyofreportingcould alsobea significant factor, especially when safetyand security conditionsaredeficient.Thoughnodirectcorrelationorcauseand effect can be drawn, it is notable that the peak of diarrheal infectious occurs in mid-2019 in the Idlib governorate; this is aroundthetimewhenthisgovernoratesawtheheaviestattackson itswaterinfrastructureaswellaspopulationmovementsrelated toanescalationofviolence(Figure3a).IntheAleppogovernorate, therewasanintensificationofattacksonwaterinfrastructurefrom AugusttoSeptember2016;thepeakindiarrhealcasesinmid-2017 washigherthanthatseeninpreviousyears(Figure3a).However, theextenttowhichthedisruptionofWASHaffectsthesecannotbe directlycorrelated,particularlyasmitigationandcopingmeasures, e.g.,diggingwells,importingwatertanks,willhaveaneffect.In addition, the impact of damage to other infrastructure, e.g., electricity,whichisrequiredforpumps,cannotbequantified.

WeaponizationofwaterinSyria

The literature review from which the timeline is drawn identiﬁes a number of instances in which the interruption of water(andelectricitywhichalsoaffectswatersupplies)hasbeen usedasaweaponduringtheconﬂict(WorldBankGroup,2017).

Thisweaponizationofwaterhashaddetrimentaleffectsonpublic Figure2. TimelineofmajorattacksanddisruptionofwaterinfrastructureinAleppogovernoratebetween2011and2018(duringwhichtherewerenomajorattacksinIdlib governorate)andinIdlibgovernoratein2019(whentherewerenofurthermajorattacksinAleppogovernorate).Referencestothenotedeventsareprovidedinthetextand here,asfollowing:Box1(WorldBankGroup,2017).Box2(Boghani,2012).Box3(Cockburn,2014;StrategicForesightGroup,2014).Box4(StrategicForesightGroup,2014).

Box5(Reznick,2016).Box6(SyrianObservatoryforHumanRights,2015).Box7(UNICEF,2015).Box8(Tokmajyan,2016).Box9(Oxfam,2016;TheGuardian,2016).Box10 (ShapiroandHobson,2017;UN-OCHA,2016).Box11(Alwaght,2017;Krzymowski,2019).Box12(Cappelaere,2019).Box13(TheNewArab,2019).Box14(WFP,2019).

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healthinSyriasincethestartoftheconflict.Thelackofcleanwater hasproducedafertilegroundforcommunicablediseasestospread within communities, including polio, hepatitis A and diarrheal diseases(Berkley,2017;Friedrich,2016;Sparrowetal.,2016).In 2013,poliore-emergedforthefirsttime in15yearsduetothe decreased number of immunizations issued by compromised hospitals (WHO, 2013). Such attacks on WASH and their consequencescouldrepresentaformofindirectbiologicalwarfare where,ratherthantheuseofbiologicalweapons,byundermining public health measures, communicable disease outbreaks are essentially‘weaponized’(Bernardetal.,2020).Childrenunderthe ageof5are20timesmorevulnerableandaremorelikelytodie fromadiarrhealdiseasethanviolencefromtheconflict.

More broadly, the literature identiﬁes other indirect health impactsofattacksagainstwater.Incasesofchemicalattackssuch asinDamascusin2013,thelackofwateralsomeantindividuals were inefﬁciently decontaminated, andthus symptoms of the nerve agent were able to persist and spread (Sparrow, 2014;

UNICEF,2019).Attacksonwatersourcesandfacilitieshavemeant, in some cases, that drinking water was contaminated with irrigationwater,andinothers,theremovedsupplyofelectricity from citiesthatdepend onhydroelectricdams (Reznick, 2016;

Rudaw,2018).Theriskofmalnutritionincreasesascropssuchas wheatthatreliedonthemainwatersupplies,especiallyduring thedrought,hadbeendirectlyaffected,andthus, theiryield in 2018reachedarecord lowinthelast 30years (Akbarzadaand Mackey,2018).

Syria sharesits main rivers (Euphrates, Tigris, Orontes, and Yarmouk)withneighboringcountriesandreliesontheEuphrates- Tigrisbasin ineasternTurkeyformostof itswatersupply; the EuphratesriveranditstributariesisbyfarthemostcriticalinSyria (Factbook). Water resource management in Syria faces several challenges, including the absence of a legal framework on integrated water resources management, weak institutions in charge of water resources management, and the increase in population.Assuch,therearemultipleexistingpressuresonwater resourcesintheregion,includingtheimpactofclimatechange;the additionaldestructionofWASHinfrastructure,therefore,actsasan additional,exacerbatingfactor(MouradandAlshihabi,2015).

Strengthsandlimitations

Fortheliteraturereview,therewerefewcrediblesourcesand, althoughwetriangulatedtoverifyparticularinstances,werelied onnewsarticlesorgreyliteraturegiventhepaucityofscholarly literaturedescribingspecificattacks.However,somereports,for example, from the World Bank and Mourad et al., provided verifiableinformation(MouradandAlshihabi,2015;WorldBank Group,2017).Additionally,mostofthesignificantdisruptionsto waterinIdlibandAleppogovernoratesoccurredinthemaincities (Maarat al-Numan, Aleppo) with feweroutside of these cities;

however, these cities are among the most populated in the governorates.DatafromEWARNandEWARSarecollectedduring conﬂict; however, despite the development of networks and Figure3.(a)TrendsintotaldiarrhealdiseasecasesinIdlibandAleppogovernorates,asreportedbyEWARN(A)andEWARS(B).(b,c,d):Figure3bandcshowthecase numbersandproportionsofotheracutediarrhea,acutebloodydiarrheaandacutejaundicesyndromeintheunder-5and5+yearsagegroups;Figure3dshowscasenumbers foracutebloodydiarrheaandacutejaundicesyndromeonly(excludingotheracutediarrhea).