Mohamed ELsonpaty, Adel Aldaghbashy, Zeki Al-Droubi, and Hazem Badr examine the link between conflict in disease, in an article originally written for the Science and Development Network (SciDev.Net)
Child with cutaneous leishmaniasis awaiting treatment in Kabul, Afghanistan (image: WHO/C Black)
Conflict has left the door wide open for epidemics in the Middle East, letting leishmaniasis into Syria, polio back into Iraq after 14 years, and – after two violent waves – cholera to spread across Yemen once again.
Sometimes, more people die from diseases associated with war, or the aftermath of war, than from the conflict itself. The effect of epidemics lingers across time as well as borders, says Ghassan Abu Sitta, head of the plastic surgery department at the American University Hospital in Beirut, Lebanon.
Abu Sitta is a Palestinian from Gaza who has lived through the last three attacks launched by Israeli occupation forces on the district, providing field assistance to the injured. He says that history has shown the links between war and disease emergence time and time again, in different parts of the world.
"War and armed conflict create a hostile environment to human health, and (to) life," he says.
Samer Jabbour, co-chair of the Lancet–American University of Beirut Commission on Syria: Health in Conflict, believes that the conditions leading to the spread of epidemics in conflict areas are related to two factors: first, weaknesses in the health sector before conflict begins, or the absence of any health system at all; and second, the collapse of the sector during conflict.
“These … combine to create the tragedy we face now," Jabour says, citing Yemen as an example. “The public health infrastructure was in a bad state, and this deteriorated during the conflict, leading to the cholera epidemic.”
The spread of diseases and failure to act swiftly in times of war do not affect countries of the region alone, according to Mohammed Jassim, director of the epidemics’ Early Warning Alert and Response Network (EWARN) in the Syrian Assistance Co-ordination Unit. “Even developed countries are unable to react swiftly," he says.
EWARN is a global surveillance system set up to support preparedness and response in parts of the world that are affected by war or natural disasters, such as volcanoes and tsunamis, Jassim tells SciDev.Net, adding that it evaluates the spread of disease before the situation gets exacerbated. "We try to alert partners such as WHO, UNICEF, and other organisations and health directorates in a timely manner so that a quick response can be taken."
Yousuf Al-Haderi is the official spokesman for the Yemeni Ministry of Health, in the government of the Ansar Allah Houthi rebel movement. He points out that: "The role of global and international organisations grows during wars and conflicts, and sometimes they are the only option.”
The ministry’s “only role is to help those organisations to support the health sector in the country," adds Al-Haderi.
Mamunur Rahman Malik, director of the Infectious Risk Assessment Unit at the WHO Regional Office for the Eastern Mediterranean, notes: "The organisation has many roles in countries of the region that suffer from war and conflict, such as applying epidemics’ early warning systems, (and) assessing risks periodically to ensure optimal preparedness.” It also leads and co-ordinates efforts during outbreaks, provides technical guidance and support timely, high-quality medical interventions.
Other international organisations adopt a different approach.
"Our priority … is immunisation programmes, whether routinely in the regions with few conflicts or immunisation campaigns in refugee camps,” says Khaled Al-Shaikh from Doctors Without Borders (Médecins Sans Frontières or MSF). The organisation has started vaccinating evacuees and refugees since conflicts erupted in the region in 2012, adds Khaled Al-Shaikh, who is acting Middle East Program Officer for MSF’s operations in Yemen, Jordan, Syria, Iraq and Lebanon.
Working in conflict areas
Conflict means some specific challenges for efforts to contain epidemics, according to Malik.
"The main challenges … are the difficulty of reaching those in need of medical care because of insecurity, and the difficulty of delivering medical assistance due to the destruction of the transport and communications as well as the health system infrastructures,” he explains. Malnutrition and poor immunity also mean diseases can spread faster, while funding is often too limited to mount an effective response.
Al-Shaikh adds more to the list. :There’s the absence of routine immunisation, prevention and treatment services,” he says, as well as antibiotic resistance, “and of course the limited capabilities of medical personnel, equipment, and medicines in comparison to the number of those who need medical care.”
Challenges aside, Al-Haderi is frustrated by the poor capacity to contain the crisis in Yemen. "To talk about the death of just one person because of cholera in the 21st century is shameful. How could we talk about 2,100 registered deaths, and many more people … who died of this disease in Yemen because of poor epidemic monitoring?"
He believes that a key obstacle is the capacity for sound management of the support available from international organisations, stressing the need for astute national leadership to channel aid appropriately.
"There are good efforts for which we thank international organisations,” adds Al-Haderi, “but they do not rise to the level of Yemen’s health needs.” He believes their actions fall short of the budget available to them, and the state of emergency in the country.
Keeping within borders
Epidemics triggered by conflict often extend beyond the countries where they originate, and into neighbouring states – they know nothing of borders, explains Jabbour.
For example, the outbreak of polio in Syria in 2014 was declared a health emergency of international concern as the disease could have spread to neighbouring countries, such as Turkey.
The WHO takes diseases that spread in conflict areas very seriously, notes Mohamed Jenidi, director of the General Directorate of Communicable Diseases at the Preventive Medicine Department of the Ministry of Health and Population in Egypt.
"The (General Directorate) administration sends periodic bulletins to the quarantine (administration) at Egyptian airports and ports, which list countries specified by the WHO, so that accurate medical disclosure can be signed by passengers coming from these countries," he tells SciDev.Net.
Responding to the cholera outbreak in Yemen, for example, Jenidi’s department recently sent a bulletin calling for monitoring and testing passengers arriving from the country. Similar alerts for passengers from countries in Sub-Saharan Africa have been sent after outbreaks of Rift Valley fever and Lassa fever.
Zoubir Harrat, director of the Institut Pasteur in Algeria, stresses the importance of continuous public health monitoring to prevent epidemic disease from spreading in the first place. A directive that requires health authorities to act as soon as a case is identified has been enshrined in a new health law that Algeria ratified in May 2018.
According to Harrat, the institute prepares detailed reports on what needs to be done for prevention, especially after the Hajj season, when authorities are more likely to see diseases spreading as a result of large congregations in Mecca.
Jabbour stresses the four basic principles of humanitarian work that need to apply in every case: humanity, neutrality, impartiality, and independence. "But the problem is that those principles are violated by the conflicting parties," he says.
"The solutions that are being implemented are more temporary solutions than long-term radical ones,” adds Jabbour. Under this scenario, he believes: “Any efforts will be inadequate as long as the conflict continues”.