Aleppo Evil

AL-SALAMA, Syria — A crowd gathers at the center of Bab al-Salam, a refugee camp on the Turkey-Syria border that is home to some 13,500 internally displaced Syrians. Children sit at their mothers’ feet, playing with plastic toys in the melting mud. One boy’s cheeks are pocked with small red dots; a boy next to him, wearing nothing but a diaper, has a large crusted lesion on his leg — signs of an infectious skin disease that is spreading throughout Syria and the neighboring region.

Since war came to Syria a little more than two years ago, the country has been transformed into a public health nightmare. Gastroenteritis, which causes severe diarrhea, vomiting, and abdominal pain, is ubiquitous among displaced populations — both inside and outside Syria — and a measles epidemic is currently sweeping the northern portion of the country. (At least 7,000 cases of the disease have been detected since 2011, according to Doctors Without Borders.) An outbreak of water-borne diseases such as hepatitis, typhoid, cholera, and dysentery, meanwhile, is all but "inevitable," according to the World Health Organization (WHO).

But in camps like Bab al-Salam, it is a silent, flesh-eating parasite that is literally leaving its mark on the population. Cutaneous leishmaniasis, also known as the "Aleppo evil" or the "Aleppo boil," is carried by sand flies and causes painful lesions that can become secondarily infected, often resulting in disfigurement. Another form of leishmaniasis — visceral — affects the spleen and liver, and it is the second-largest parasitic killer in the world after malaria. Mercifully, it is only the nonlethal parasite that is coursing through the Syrian countryside, where years of fighting has made seeking medical treatment extraordinarily difficult. Still, the parasite leaves its victims scarred for life.

According to the WHO, which has set up an early-warning system to monitor the disease in all 14 of Syria’s governorates, 1,047 cases of cutaneous leishmaniasis were reported between April 14 and May 18 of this year. The majority of those cases occurred in Aleppo, where the disease was endemic prior to the crisis, but an increasing number have cropped up among internally displaced people in Syria’s Tartus governorate, where the disease was previously unreported. Thousands of additional cases have been reported in bordering countries in the last year.

Still, the WHO has yet to classify the increasing number of cases as an official outbreak, which would require a twofold increase in the number of reported cases among all age groups since last year. "Despite articles or videos circulating in the media talking about an ‘outbreak’ of cutaneous leishmaniasis, WHO has not received up to date any systematic epidemiological data to ascertain that," Jose Postigo, an expert on leishmaniasis at the WHO, told Foreign Policy in an email. "But the disease is highly endemic in parts of the country."

If one assumes the conflict hasn’t depressed the rate of reporting, the numbers recorded by the WHO aren’t significantly different from those in previous years (the Aleppo governorate, where the vast majority of cutaneous leishmaniasis cases occur, reported 18,603 cases in 2008, for example). But the war has increased the risk that the parasite will be carried to neighboring countries, according to Postigo. Already, the WHO has received some 1,300 reports of leishmaniasis cases in Lebanon, Jordan, Turkey, and Iraq in the past year. In all likelihood, many more cases remain unreported, whether because of poor education, lack of access to medical treatment, or logistical problems associated with mass migration.

According to the WHO’s eastern Mediterranean regional office, accurate data on the number of leishmaniasis cases is difficult to gather because of the movement of Syrians inside the country and within neighboring countries. Some 1.6 million refugees have fled Syria since the violence began 27 months ago, and another 7,000 arrive daily in bordering countries, according to the United Nation’s refugee agency, UNHCR. Lack of data from the clinical level also hampers efforts to map the disease’s spread, according to Samantha Crago, who works on the Syria regional response team at Save the Children, which helps deliver medical and humanitarian aid inside Syria. What is clear, she says, is that the international community isn’t doing enough to treat the disease.

"Overall, health facilities are overwhelmed across the country with critical shortages of staff, drugs, equipment. This can be assumed also for [cutaneous] leishmaniasis, which is non-life-threatening, so treatment options are not widely available or prioritized," says Crago. "Organizations were distributing bed nets and some were providing spraying [for sand flies], but many areas such as inner cities and other higher-conflict-intensity locations are harder to reach to provide this support."

The WHO’s Postigo claims that medication for cutaneous leishmaniasis is readily available in Syria and that the WHO has sent medication to Lebanon and Turkey in preparation for the expected uptick in cases among Syrian refugees. In camps like Bab al-Salam, however, medicine shortages persist. Doctors with Medical Relief for Syria (MRFS), a nonprofit organization that runs a medical center in the camp, say they have only four types of antibiotics, all of which treat symptoms associated with gastroenteritis. As a result, they are unable to treat leishmaniasis patients with the necessary doses of sodium stibogluconate, which must be injected directly into the boil. The situation is the same in many refugee camps in bordering countries. As of August 2012, for example, the Zaatari refugee camp in Jordan — now home to some 180,000 Syrians — was only treating trauma patients because of a shortage of doctors.

There is no one single aid organization providing relief in Syria or in refugee camps in bordering countries. Medical supplies for Syrians suffering from leishmaniasis both inside and outside the country come from a patchwork of local aid organizations, private donors, and international aid organizations like the WHO and UNHCR — all of which struggle to get medicine to those in Syria who are in need.

In past years, Save the Children has teamed up with the WHO to spray chemicals in sand-fly breeding grounds, thereby reducing the chances of a leishmaniasis outbreak. But this year, according to Crago, preventive spraying was disrupted by the fighting. As a result, he expects the disease to spread more quickly than in previous years.

The lack of medical supplies and preventive spraying isn’t the only obstacle to containing leishmaniasis. Poor education about what causes the Aleppo boil — and how to treat it — means that many children continue to suffer unnecessary pain and disfigurement. "Do you see what is happening to my child? Just look at this. It is because of that dirty water," one middle-aged woman told me as she pointed to a stream of garbage flowing between tents.

Most mothers in Bab al-Salam whose children had visible sores thought they were caused by poor camp conditions. Doctors with MRFS seemed to shrug off the disease — and the refugees’ ignorance of how it spreads.

"They always say it is from the water. They don’t understand they probably got the disease before they came here," said one doctor. "I am not as worried about the leishmaniasis as I am about the possible cholera outbreak. The summer months are coming."

According to Peter Hotez, a professor of molecular virology and microbiology at Baylor College of Medicine and founding dean of its National School of Tropical Medicine, lack of preventive medicine — like nets and spraying for sand flies — is the main driver of leishmaniasis infections in Syria. As a result, Hotez and his team are working to develop a vaccine that prevents the ulcers from forming — though it is still in early, pre-clinical stages.*

Treatment with sodium stibogluconate, moreover, "requires intramuscular injections" and prolonged treatment by specialized doctors, according to Hotez — an unrealistic scenario for victims of the disease still living in war-torn areas.

Another force propelling Syria toward a devastating outbreak is the rapid deterioration of sanitary conditions within the country. Trash pickup is virtually nonexistent, and in many cities garbage has begun to collect in the streets. In places like Aleppo and the suburbs surrounding Damascus where the fighting is at its worst, there is no electricity or running water. The subsequent buildup of sewage in the streets — combined with Syria’s extreme heat — attracts the sand flies that carry leishmaniasis, according to Crago.

"Syria has been teetering on a leishmaniasis outbreak for a while," Hotez said. "It makes sense. Anytime a war like this starts, the chances of outbreak increase."

*Correction: A previous version of this article incorrectly stated that a vaccine for Leishmaniasis won’t be available for distribution for another three years. In fact, the vaccine is still in early, pre-clinical stages, so it’s difficult to say how long until it reaches the market. FP regrets the error.