Weaponizing water as an instrument of war in Syria: impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011-2019.

OBJECTIVES Investigate the weaponization of water during the Syrian conflict and correlation of attacks on water, sanitation and hygiene (WASH) infrastructure in Idlib and Aleppo governorates with trends in waterborne diseases as reported by Early Warning and Response surveillance systems. METHODS We reviewed literature and databases to obtain information on attacks on WASH in Aleppo and Idlib governorates between 2011 and 2019. We plotted weekly trends in waterborne diseases from two surveillance systems operational in Aleppo and Idlib governorates between 2015 and early 2020. RESULTS The literature review noted several attacks on water and related infrastructure in both governorates suggesting that WASH infrastructure was weaponized by state and non-state actors. Most interference with WASH in Aleppo governorate occurred before 2019 and in Idlib governorate in the summer of 2020. Other acute diarrhoea represented >90% of cases of diarrhoea; children under 5 years contributed 50% of cases. There was strong evidence (p < 0.001) of an overall upward trend in cases of diarrhoeal disease. CONCLUSIONS Though no direct correlation can be drawn between the weaponization of WASH and the burden of waterborne infections due to multiple confounders, this research introduces important concepts on attacks on WASH and their potential impacts on waterborne diseases.