Disruption to water supply and waterborne communicable diseases in northeast Syria: a spatiotemporal analysis.

BACKGROUND: In Syria, disruption to water and sanitation systems, together with poor access to vaccination, forced displacement and overcrowding contribute to increases in waterborne diseases (WBDs). The aim of this study is to perform a spatiotemporal analysis to investigate potential associations between interruptions to water, sanitation, and hygiene (WASH) and WBDs in northeast Syria using data collected by the Early Warning Alert and Response Network (EWARN) from Deir-ez-Zor, Raqqa, Hassakeh and parts of Aleppo governorates. METHODS: We reviewed the literature databases of MEDLINE and Google Scholar and the updates of ReliefWeb to obtain information on acute disruptions and attacks against water infrastructure in northeast Syria between January 2015 and June 2021. The EWARN weekly trends of five syndromes representing waterborne diseases were plotted and analysed to identify time trends and the influence of these disruptions. To investigate a potential relationship, the Wilcoxon rank sum test was used to compare districts with and without disruptions. Time series analyses were carried out on major disruptions to analyse their effect on WBD incidence. RESULTS: The literature review found several instances where water infrastructure was attacked or disrupted, suggesting that water has been deliberately targeted by both state and non-state actors in northeast Syria throughout the conflict. Over time, there was an overall upwards trend of other acute diarrhoea (OAD, p < 0.001), but downwards trends for acute jaundice syndrome, suspected typhoid fever and acute bloody diarrhoea. For the major disruption of the Alouk water plant, an interrupted time series analysis did not find a strong correlation between the disruption and changes in disease incidence in the weeks following the incident, but long-term increases in WBD were observed. CONCLUSIONS: While no strong immediate correlation could be established between disruptions to WASH and WBDs in northeast Syria, further research is essential to explore the impact of conflict-associated damage to civil infrastructure including WASH. This is vital though challenging given confounding factors which affect both WASH and WBDs in contexts like northeast Syria. As such, research which includes exploration of mitigation after damage to WASH is essential to improve understanding of impacts on quantity and quality of WASH. More granular research which explores the origin of cases of WBDs and how such communities are affected by challenges to WASH is needed. One step towards research on this, is the implementation of adequate reporting mechanisms for real time tracking of the WASH attacks, damages, direct effects, and likely impact in conjunction with environmental and public health bodies and surveillance systems.

AMR and Covid-19 on the Frontline: A Call to Rethink War, WASH, and Public Health.

This Viewpoint calls for a greater understanding of the role that water plays in the transmission of anti-microbial resistance and covid-19 in protracted urban armed conflict, in order to develop a 'pathogen-safe' practice. It argues that dealing with the twin threats is difficult enough in the best of circumstances, and is so little understood in war zones that surgeons and water engineers now question if their practice does more harm than good. Experience suggests that the known transmission routes are complicated by a great number of factors, including the entry of heavy metals through bullets in patients' wounds, hospital over-crowding, mutation in treated water or wastewater, and other threats which endure long after the bombing has stopped. The skeleton research agenda proposes greater sewage surveillance, testing of phages and monitoring of treatment designed to dispel or substantiate these assertions.

Recommendations for dealing with waste contaminated with Ebola virus: a Hazard Analysis of Critical Control Points approach.

OBJECTIVE: To assess, within communities experiencing Ebola virus outbreaks, the risks associated with the disposal of human waste and to generate recommendations for mitigating such risks. METHODS: A team with expertise in the Hazard Analysis of Critical Control Points framework identified waste products from the care of individuals with Ebola virus disease and constructed, tested and confirmed flow diagrams showing the creation of such products. After listing potential hazards associated with each step in each flow diagram, the team conducted a hazard analysis, determined critical control points and made recommendations to mitigate the transmission risks at each control point. FINDINGS: The collection, transportation, cleaning and shared use of blood-soiled fomites and the shared use of latrines contaminated with blood or bloodied faeces appeared to be associated with particularly high levels of risk of Ebola virus transmission. More moderate levels of risk were associated with the collection and transportation of material contaminated with bodily fluids other than blood, shared use of latrines soiled with such fluids, the cleaning and shared use of fomites soiled with such fluids, and the contamination of the environment during the collection and transportation of blood-contaminated waste. CONCLUSION: The risk of the waste-related transmission of Ebola virus could be reduced by the use of full personal protective equipment, appropriate hand hygiene and an appropriate disinfectant after careful cleaning. Use of the Hazard Analysis of Critical Control Points framework could facilitate rapid responses to outbreaks of emerging infectious disease.

The analytical framework of water and armed conflict: a focus on the 2006 Summer War between Israel and Lebanon.

This paper develops an analytical framework to investigate the relationship between water and armed conflict, and applies it to the 'Summer War' of 2006 between Israel and Lebanon (Hezbollah). The framework broadens and deepens existing classifications by assessing the impact of acts of war as indiscriminate or targeted, and evaluating them in terms of international norms and law, in particular International Humanitarian Law (IHL). In the case at hand, the relationship is characterised by extensive damage in Lebanon to drinking water infrastructure and resources. This is seen as a clear violation of the letter and the spirit of IHL, while the partial destruction of more than 50 public water towers compromises water rights and national development goals. The absence of pre-war environmental baselines makes it difficult to gauge the impact on water resources, suggesting a role for those with first-hand knowledge of the hostilities to develop a more effective response before, during, and after armed conflict.

Water demand management in Yemen and Jordan: addressing power and interests.

This paper investigates the extent to which entrenched interests of stakeholder groups both maintain water use practice, and may be confronted. The focus is on the agricultural sectors of Yemen and Jordan, where water resource policymakers face resistance in their attempts to reduce water use to environmentally sustainable levels through implementation of water demand management (WDM) activities. Some farmers in both countries that have invested in irrigated production of high-value crops (such as qat and bananas) benefit from a political economy that encourages increased rather than reduced water consumption. The resultant over-exploitation of water resources affects groups in unequal measures. Stakeholder analysis demonstrates that the more 'powerful' groups (chiefly the large landowners and the political elites, as well as the ministries of irrigation over which they exert influence) are generally opposed to reform in water use, while the proponents of WDM (e.g. water resource managers, environmental ministries and NGOs, and the international donor community) are found to have minimal influence over water use policy and decisionmaking. Efforts and ideas attempted by this latter group to challenge the status quo are classified here as either (a) influencing or (b) challenging the power asymmetry, and the merits and limits of both approaches are discussed. The interpretation of evidence suggests current practice is likely to endure, but may be more effectively challenged if a long-term approach is taken with an awareness of opportunities generated by windows of opportunity and the participation of 'overlap groups'.

Asymmetric abstraction and allocation: the Israeli-Palestinian water pumping record.

The increased attention given to international transboundary aquifers may be nowhere more pressing than on the western bank of the Jordan River. Hydropolitical analysis of six decades of Israeli and Palestinian pumping records reveals how ground water abstraction rates are as asymmetrical as are water allocations. The particular hydrogeology of the region, notably the variability in depth to ground water, variations in ground water quality, and the vulnerability of the aquifer, also affect the outcome. The records confirm previously drawn conclusions of the influence of the agricultural lobby in maintaining a supply-side water management paradigm. Comparison of water consumption rates divulges that water consumed by all sectors of the farming-based Palestinian economy is less than half of Israeli domestic consumption. The overwhelming majority of "reserve" flows from wet years are sold at subsidized rates to the Israeli agricultural sector, while very minor amounts are sold at normal rates to the Palestinian side for drinking water. An apparent coevolution of water resource variability and politics serves to explain increased Israeli pumping prior to negotiations in the early 1990s. The abstraction record from the Western Aquifer Basin discloses that the effective limit set by the terms of the 1995 Oslo II Agreement is regularly violated by the Israeli side, thereby putting the aquifer at risk. The picture that emerges is one of a transboundary water regime that is much more exploitative than cooperative and that risks spoiling the resource as it poisons international relations.