Aleppo Evil

Meet the flesh-eating parasite that's sweeping across Syria.

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. 




Is Obama a Berliner?

The U.S. president arrives in Germany with chill hanging over relations.

BERLIN — Obama: Ist er ein Berliner? The German weekly Die Zeit posed this question a few days ahead of the U.S. president's visit to the city on Tuesday, June 18. The article -- and Obama's visit -- were timed to coincide with the 50-year commemoration of President John F. Kennedy's famous speech, but the mood here feels less a celebration of a friend in Washington right now than an expression of disappointment over revelations about his role in the NSA's vast surveillance program, which devoted considerable resources to monitoring Germany. Outrage over the PRISM program prompted Der Spiegel to describe  Obama as "The Lost Friend."

Obama's first visit as president to Berlin will stand in sharp contrast to his euphoric reception in 2008 as a candidate. As a senator, he delivered a speech to a crowd of 200,000 at Berlin's Victory Column. This time around, Obama's appearance is significantly scaled down, with at most 8,000 attendees scheduled to appear at the Brandenburg Gate, the symbol of German unification. But how much lasting damage have the latest revelations really done?

Germany's prickly response to muscular American security measures is nothing new, of course. Famously, in 2002, former Justice Minister Herta Däubler-Gmelin equated America's war on terror to Nazi Germany, saying "Bush wants to divert attention from domestic problems.... Hitler also did that." As President George W. Bush wrote in his memoir, "It was hard to think of anything more insulting than being compared to Hitler by a German official."

But in this case, the German reaction is somewhat more understandable -- and hits even closer to home. Germany, as it was revealed in documents leaked by former CIA contractor Edward Snowden, was the most monitored EU country by the National Security Agency. Anger over the snooping affair triggered Markus Ferber, a member of the European Parliament allied with Chancellor Angela Merkel's party to quip, "I thought this era had ended when the DDR fell," referring to the official name of communist East Germany. Similarly, TV host Sonia Mikich delivered a commentary on the news show Tagesthemen in which she referred to the NSA's leaked PRISM program as the "United Stasi of America" -- a reference to East Germany's notoriously repressive security service.

And yet the PRISM row is not likely to overshadow Obama's visit. A day ahead of the Merkel-Obama parley in Berlin, Merkel defused the controversy by defending Internet surveillance and her government's cooperation with the U.S. intelligence establishment. "We are quite dependent on that relationship and we also need to ensure we can act ourselves and that we aren't at the mercy of terrorists," said Merkel.

The disclosure on the weekend that Germany's foreign intelligence agency (BND) pumped an additional 100 million euros into its own Internet monitoring system further suggests that there is -- at least in official circles -- not a great deal of discomfort with the counterterrorism electronic dragnet, even given the country's troubled history with surveillance.

We still don't know much about why the NSA was targeting Germany in particular, but recent history provides a number of plausible explanations.

For example, the United States, based on actionable intelligence, issued a travel advisory warning to Germany and France in 2010 because, as it later turned out, German jihadists were on their way back from the Afghanistan/Pakistan war theater to Europe with the intention of inflicting damage on "Europe's economy." In 2011, Germany's intelligence and police services were humiliated after Frankfurt Airport employee Arid Uka, who was born in Kosovo and raised in Germany, gunned down two U.S. servicemen. Uka had become something of an online jihadi activist in the months leading up the attack. In the aftermath, German officials conceded that they lacked the trained Arabic-language specialists needed to analyze potential terror threats.

Compounding U.S. worries about nefarious individuals within Germany is the growth of members of Hezbollah and other terrorist groups in the Federal Republic. Germany's national intelligence agency, the Office for the Protection of the Constitution (Verfassungsschutz), which issued an alarming report this month documenting a spike in the number of Islamist activists in the country, from 38,080 in 2011 to 42,550 in 2012. Berlin in particular, as it turns out, is a hub of Hezbollah activists, with 250 members in the capital city, and a total of 950 throughout Germany. According to the report, the followers of Saudi Arabia's Wahhabi ideology increased from 3,800 to 4,500.

It is perhaps for these threats, among others, that Interior Minister Hans-Peter Friedrich defended Obama in an interview with Die Welt am Sonntag over the weekend, saying is the over-the-top comparisons in the media are "not how one deals with friends that are our most important partners in the fight against terrorism."  Friedrich added that he was thankful for the close cooperation with U.S intelligence agencies, stressing that America's intelligence information prevented many terrorist attacks in the planning stages and saved lives -- a likely reference to the wave of attacks planned by the second 9/11 cell in Hamburg.

Spin aside, the recent leaks may give some of the visit's photo-ops unwanted overtones. The White House is keen to play up the JFK connection, but Obama's visit also coincides with the anniversary of the June 17, 1953, East German workers' revolt against the communist regime of Walter Ulbricht -- the first mass protest against the Soviet-DDR axis, though admittedly not an event well known outside of eastern Germany. Soviet tanks smashed the upheavals that spread across cities in the East, increasing the paranoia of the regime. Michelle Obama is slated to visit the Berlin Wall Memorial with Merkel's somber husband, Joachim Sauer.

But the complex contours of Berlin's history contrast sharply with the nut-and-bolts working relationship that marks the Obama-Merkel tenure. Though ties between Merkel and Obama are reportedly cool (she famously rejected his wish to deliver a talk in front of the Brandenburg Gate as a candidate back in 2008), the two share a common worldview and temperament. Both are pragmatic, domestically-driven problem-solvers, largely consumed with regenerating job growth, competitiveness, and infrastructure. They also share non-interventionist foreign policy instincts. Both have been reluctant to wade into the Syrian conflict, and Obama's withdrawal from Iraq and Afghanistan resonate with Merkel's German electorate.

In fact, the Obama's most outspoken foreign-policy critics have leveled similar criticisms of Merkel. While in Berlin last week for the Henry A. Kissinger Prize ceremony at the American Academy, Sen. John McCain told the large business daily Handelsblatt that Germany failed to show leadership during the revolts in Libya and Syria. Germany's government abstained from United Nations Security Council vote authorizing a no-fly zone in Libya and remains vehemently opposed to delivering lethal aid to the Syrian rebels. McCain said the consciousness in Germany is too narrow, and ignores the need for a "military component of foreign policy."

But on the 50-year anniversary of Kennedy's monumental tribute to the democratic bastion of West Berlin in the heart of communist East Germany, Obama will have an opportunity to make history. It's unclear what message he will relay. In 1963, Kennedy provided the world with assurance that the U.S. military had the power and will to blunt Soviet aggression. Don't count on Obama to echo this martial message of freedom: according to the White House, Obama will stress the "shared history" of German-American relations -- with views toward the past triumph over communism and the precarious challenges of contemporary international security.  

In fact, it's the U.S. president's reluctance to project American power to every corner of the globe that resonates among Germans. In a country where lingering anti-George W. Bush sentiments still run deep, this accounts for a great deal. During the former president's visit at the height of the Iraq War in 2002, Bush was met with massive anti-American protests and disruptions in parliament. And while Germans are still none too thrilled with Obama's drone policies or inability to close Guantanamo -- and now add the NSA surveillance program to that list of complaints -- at least he's not his predecessor. We'll see if that still counts for something.