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LONDON: The collapse of Bashar Assad’s regime has led to a sharp rise in preventable diseases that festered during the 14-year war in Syria, with new research warning of a tuberculosis resurgence and a cholera outbreak amid fresh displacement in some regions and a broken health system.

In northwest Syria, more than 2,500 TB patients were identified between 2019 and 2025, including 47 cases of multidrug-resistant TB, according to the World Health Organization.

Similar gaps in TB care have plagued the Democratic Autonomous Administration of North and East Syria, where diagnostics and treatment programs launched in 2018 collapsed after the Daesh attack on the Hasakah prison in January 2022.

Official figures under Assad consistently painted a far rosier picture. Before his overthrow on Dec. 8 in an offensive spearheaded by rebels now in power in Damascus, Syria’s Health Ministry said TB rates had dropped from about 21 per 100,000 people in 2010 to 17 per 100,000 in 2023.

A report in Science Direct, by mostly Syrian doctors, published on July 1 suggests that the real toll is far higher, citing chronic underdiagnosis, underreporting and the exclusion of non-regime areas.

With Assad gone, opportunities for better disease surveillance are emerging, but uncertainty prevails.

“The transition has opened space to knit Syria’s fragmented surveillance into a single, more accountable system,” Anas Barbour, the Syria country representative of the US-based NGO MedGlobal, told Arab News.

“Previously parallel early-warning streams are being integrated, and community-based reporting is expanding in places that were hard to reach.”

Still, he cautioned, capacity is fragile. “Some facilities were damaged, many health workers have been displaced, and access can change quickly,” he said. “Partners are sustaining early-warning coverage while the national system is rebuilt.”

Those concerns were echoed by Dr. Aula Abbara, an infectious disease consultant in London and co-founder of the Syria Public Health Network.

According to her, the fate of Syria’s two existing surveillance systems — the Early Warning and Response Network (EWARN) and the Early Warning and Response System (EWARS) — “remains uncertain as a process of merger occurs.”

“The two systems are quite different in operation and effectiveness, and now, some months later, there is a process of merging these two systems,” Abbara told Arab News. 

The existence of two parallel surveillance systems reflects the broader fragmentation of Syria’s health infrastructure. Dr. Yaser Ferruh, who heads the communicable diseases department at the health ministry, explained that while both programs used the same approach, each had distinct features.

EWARS, launched with the WHO’s support, operated through the official framework and grew to cover more than 1,800 health centers, providing broad nationwide data.

“This program was built within the official institutional framework and was distinguished by its wide geographic coverage and a large number of reporting health centers, which in recent years exceeded 1,800 centers,” Ferruh told Arab News. “This allowed it to provide comprehensive nationwide data.”

EWARN, by contrast, was run by the Assistant Coordination Unit with international backing and focused on opposition-held areas. It was “more flexible in the field, reaching local communities under difficult conditions,” Ferruh said.

“It was also characterized by rapid reporting and higher timeliness, as its reports were submitted faster and with higher compliance than EWARS.”

He said that “the number of cases reported through EWARN was much higher, particularly in densely populated areas in northern Syria.”

While both played critical roles in tracking polio, cholera and influenza outbreaks, operating in parallel also created duplication, inconsistent definitions and difficulties in unifying data, Ferruh said.

Efforts were now underway to merge the two into a single national system, he said.

The Science Direct study, titled “Tuberculosis: The Insidious Threat that Compromises Health in Post-Assad Syria,” concluded that years of war left the health system fractured under competing authorities, producing gaps in access to care.

The toll remains visible. Since 2011, about half of hospitals and most clinics have been damaged or destroyed. By March, the WHO said only 57 percent of hospitals and 37 percent of primary health centers were fully functional, while 70 percent of health workers had fled the country.

Even those still operating struggle with shortages of supplies, outdated equipment and crumbling infrastructure. Many hospitals function at minimal capacity or face closure due to lack of funding. In the northwest and northeast, 246 facilities are at risk of shutting down without new resources.

Those conditions, coupled with poverty, malnutrition, unsafe water, poor sanitation and overcrowding, have contributed to the return not only of TB but also cholera — especially among displaced people, detainees and rural communities, according to the Science Direct study.

Between August and December last year, 1,444 suspected cholera cases and seven deaths were reported in Syria, according to the WHO, with the highest caseloads in Latakia, Hasakah, Aleppo and displacement sites such as Al-Hol camp in the northeast.

“Cholera came roaring back because the basics of safe water and sanitation are still broken,” Barbour said. “Drought, damaged water networks, population displacement and over-stretched camps mean families often rely on unsafe water. Warmer months add risk.”

Years of war have devastated water infrastructure. About two-thirds of facilities are damaged or destroyed, according to Fanack Water. 

The International Committee of the Red Cross said that before 2010, more than 90 percent of Syrians had reliable access to safe water; by 2021, only half of systems functioned properly. In Deir Ezzor, water pumping capacity fell 90 percent during sieges and airstrikes, a 2015 Bellingcat investigation found. 

Compounding the problem is a worsening drought crisis this year, with experts warning that the country’s entire water cycle is collapsing. A new Mercy Corps report found rainfall has shrunk nearly 28 percent nationwide and more than 30 percent in regions such as Deraa, Idlib, and Aleppo.

Groundwater reserves are severely depleted, with baseflow down 80 percent across the country and over 90 percent in some areas.

Abbara agrees that the cholera resurgence was driven mainly by “extensive damage and interruption to WASH (water, sanitation and hygiene) infrastructure — both deliberate and indirect.”

She said “contaminated rivers also spread the disease through crops and communities, while delays in oral cholera vaccine requests (by the former Ministry of Health) and procurement led to delayed distribution to some geographies during the 2022 outbreak, leaving many with delays to protection.”

A severe cholera outbreak was declared in Syria on Sept. 10, 2022, and spread through all 14 governorates, with reports of tens of thousands of cases of suspected acute watery diarrhoea, according to the WHO.

The delays in oral cholera vaccine reaching all populations in Syria in 2022 and 2023 were partly because the Syrian Ministry of Health requested certain controls at the time, according to July 2023 research published in the National Library of Medicine.

Global shortages compounded the problem. In October 2022, health agencies switched from a two-dose to a single-dose vaccination strategy to stretch limited supply. Even so, health facilities were quickly overwhelmed.

Barbour emphasized that while vaccines help blunt outbreaks, “they can’t substitute for reliable chlorination, sewage management and hygiene services.”

Abbara agreed that for cholera, “the mainstay is improving water and sanitation, particularly as returnees come home.”

For now, humanitarian aid sustains much of Syria’s medical care, especially outside Damascus’s reach. But agencies warn that severe funding shortfalls threaten to push the fragile system closer to collapse.

“Since the fall of the regime, there is grave underfunding, impacting the hiring of experienced staff, and uncertainty across the country,” Abbara said.

She added that urgent TB intervention requires better diagnostics, active case finding in vulnerable populations such as detainees, and expanded staff training.

MedGlobal’s cholera response includes rapid case detection, treatment units, oral rehydration points, water chlorination, hygiene kits and risk communication in camps and host communities.

For TB, its efforts range from community screening and GeneXpert testing to contact tracing, nutritional support, and referral of multidrug-resistant cases for oral regimens.

“Across both, MedGlobal’s aim is to support the MoH and local health directorates, strengthening public services, filling critical gaps and ensuring that emergency actions ladder up to a stronger national system,” Barbour said.

But “access and security constraints” remain the biggest obstacles to delivering care in conflict-affected areas. “Attacks on healthcare — when they occur — undermine trust and push patients away from services,” he said.

The insecurity of life in a volatile political environment also complicates care. Insurgencies, sectarian clashes and sporadic attacks stretch across many regions, while recent violence in Suweida and the coastal governorates again resulted in damage to medical infrastructure. 

Equally disruptive, Barbour said, “are the day-to-day realities: electricity and internet outages that stall labs and surveillance, supply chain and permitting delays, and chronic underfunding that threatens continuity of care just as needs rise.”

Frequent and widespread electricity and internet failures disrupt the functioning of hospital labs, surveillance systems and health information flows needed for disease monitoring and emergency response, the WHO reported in March.

Supply chains for medicines, equipment and other essentials are fragile, strained by damaged transport links, local permitting delays and competition for scarce resources throughout Syria and the wider region. 

As Syria moves through its post-Assad transition, its shattered health system faces the twofold challenge of containing resurgent diseases while rebuilding defenses to stop their return.

The survival of new surveillance efforts, aid programs and fragile facilities under the strain of conflict, displacement and underfunding will decide whether preventable illnesses fade or persist.