In the middle part of the last decade, religious figures in Nigeria brought a halt to polio vaccination campaigns in much of the north of the country. Unsurprisingly, an outbreak of the disease occurred only a few years later, with dozens of children getting sick. It spread rapidly out of control, with strands of the disease being detected across large parts of Africa and eventually making it as far as Indonesia. In total 27 countries were affected before it was brought under control.
Dr. Hassan El Bushra, head of the World Health Organization (WHO) in Lebanon, retells the story as a warning about the danger of domino effects. “One country not responding is a threat to others,” Bushra says. In response to the logical follow on question — is Syria the new Nigeria? — he simply says “exactly.”
Since Syria’s three-year civil war began, the violence has destroyed healthcare facilities across the country – meaning vaccination programs have rapidly declined. As such, millions are now susceptible to diseases such as polio.
Polio, a disease that only affects humans, can cause paralysis and even death, with young children particularly susceptible. Prior to the Syrian war, it had been eradicated in most parts of the Middle East, with Lebanon, Syria and Iraq all last seeing cases over a decade ago. “It is a disease that is almost dying, it is vanishing. We at the WHO and the whole world are about to kill this pathogen,” Bushra says.
Yet Syria’s implosion has breathed new life into a dying plague. Hundreds of cases of the virus, which lives in water and contaminates food and sewage, have been diagnosed, with the first outbreak occurring in the eastern city of Deir ez-Zor.
“Because of the destruction of the health system in Syria, the virus has already started [spreading]. People are afraid to go to the healthcare facilities, they have become more susceptible — especially the newly born,” Bushra says. The strand that began in Deir ez-Zor has been traced as far away as Egypt, Palestine and even Pakistan. “There are no direct flights from Pakistan to Deir ez-Zor,” he says to emphasize the rapid and indirect nature of the spillover.
Indeed, in the past few weeks the first case since 2000 was confirmed in Iraq, raising the WHO’s assessment of the threat of a major outbreak in the country to high. Bushra points out that the nature of polio as a disease means that for every child who gets severe symptoms, there are many other carriers who show no signs. “One case of paralytic polio means that about 200 children were already affected by the virus,” he says.
So far, Lebanon, the country that has opened its borders to the most Syrian refugees, has avoided the disease. While there have been a few cases reported in the media as potential polio, they have as yet all been false alarms. Part of this has been good planning — together with WHO and UNICEF, the Lebanese government has just completed a fourth campaign to vaccinate hundreds of thousands of children.
These campaigns have managed to hold back the disease, according to Dr. Salim Adib, an epidemiology professor at the Lebanese University in Beirut. He points out that the vaccine is easy to provide as it is taken orally and does not require an injection and therefore the campaign has been able to reach out rapidly to refugee communities. “The government is doing more than it was expected to do,” he says.
Yet still, more is needed. A new study, seen by Executive but not yet published, raises concerns over the level of vaccinations both within local communities and particularly among Syrian refugees. The poll, conducted by the University of Sagesse, surveyed nearly 9,000 children up to 5 years of age, around 22 percent of whom were Syrian with the remainder Lebanese. What it showed were vast geographical discrepancies in the preparedness of communities to deal with polio and other infectious diseases.
While in some areas — such as Baabda and Zgharta — all sampled children that had vaccination cards were able to show they were protected, in more at-risk areas that percentage dropped rapidly. In Zahle and Hermel, areas that have seen huge influxes of Syrian refugees, the percentage of children fully protected against the disease was just 56.1 percent and 53.9 percent respectively. Overall, 88.7 percent of Lebanese but just 66.8 percent of non-Lebanese children were vaccinated.
The report suggests that more support is desperately needed in areas most at risk. The government campaign has focused more heavily on border areas, with health professionals going door to door to find those who need vaccination.
Even still, with thousands of refugees fleeing over the border every week, keeping on top of the crisis remains a daunting challenge and one that Bushra feels they may not continue to win indefinitely. In his Beirut office, he sketches a hastily drawn chart on which a gradually rising line eventually meets a horizontal one. “That is the breaking point,” he says, pointing at the intersection between the two. “And we are here,” he adds, drawing his pen only a fraction of an inch down the diagonal line. “Outbreaks are inevitable, there will be a breaking point.”
One particular concern is over the weather. As the disease is spread via feces and water, the unusually dry winter — during which experts estimate precipitation may have been down by more than 50 percent — has heightened the risks.
This is likely to be exacerbated by poor living conditions for many refugees. As the Lebanese government has yet to make a decision on the formal establishment of refugee camps, hundreds of informal settlements have sprung up — often with little clean water. “Some of [the refugees] are living in very poor sanitary environments. One of my reports shows that we have two latrines for 400 people. People have started using open space [to defecate],” Bushra says, pointing out that the disease is likely to spread much faster in such circumstances.
The strategy, Bushra says, is to continue seeking to prevent cases of polio through more immunization appeals but also to improve readiness in the event that an outbreak occurs. Talking not just about polio but the risk of other diseases, he says the key is to stockpile emergency medical supplies in at-risk areas. These supplies, if used quickly, can limit the size of outbreaks if and when they occur. “For the first three to four weeks [after an outbreak] we have to be ready. This will give us some time if we need more support from other countries,” he says.
As Lebanon struggles to deal with the threat of polio and other diseases, more funding is needed. Yet the increased risk comes at a time of growing donor fatigue, as international interest in Syria is waning and the United Nations struggles to attract the support it needs for refugees.
For Bushra the nature of polio means that it is a global, rather than Lebanese, threat. The Pakistan case already illustrates the huge dangers of ignoring the resurgence of a once-dying disease. It is, therefore, a global responsibility to deal with the crisis. “Imagine if Lebanon said: ‘We don’t have funds and we are starting to have cases of polio’,” he says. “Then the whole success of the world over the past two or three decades is at risk.”