Infectious diseases are set to spread across Syria and Iraq , with deadly consequences. That was the argument of Annie Sparrow, a public health expert at New York’s Mount Sinai Hospital, writing this week in the New York Review of Books.
"Jihadism is not the war’s only wider threat," she wrote. "For medical workers in the Middle East, it has long been apparent that the catastrophic health effects of Syria’s crisis were spilling over into neighboring countries."
Syria has been battling a polio outbreak since mid-2013,  with the crippling disease spreading across parts of the opposition-controlled north. Then in April, two cases were recorded in Baghdad  – a spread many health professionals attribute directly to the situation in Syria.
"This public health crisis is largely a result of the Syrian government’s years of attacks on the medical system in opposition-held parts of the country, with its barrel-bomb and occasional chemical attacks, as well as its withholding of basic public-health measures such as vaccination and safe water," writes Sparrow, who has made a number of trips to Syria and the border region, working with the displaced. She also said the official response from U.N. agencies has been "inadequate," with vaccination efforts "severely hampered by those agencies' mismanagement."
As the Islamic State of Iraq and Syria (ISIS) continues its march through eastern Syria and northern Iraq,  it has exacerbated the infectious disease crisis by kidnapping health workers, seizing aid convoys and triggering new exoduses of refugees.
Here, Sparrow details why the infectious disease crisis – she says polio, measles and even illnesses like rubella and tuberculosis are of concern – is on the rise in both countries, and how this week's events in Iraqi Kurdistan  could impact the spread.
Syria Deeply: How wide was vaccine coverage before the conflict?
Annie Sparrow: The coverage rates for vaccines in 2010, before the conflict, were 83 percent for polio and 82 percent for measles. And those are estimates. Meanwhile, the government keeps saying that coverage was at 99 to 100 percent for every major disease – including hepatitis and tuberculosis. But when you look at the history, all of them are in the 80 percent range, at best. And Unicef and other groups say they have a very low rate of confidence in these figures.
Syria Deeply: What led to the most recent breakout – and now, the continuation – of infectious diseases?
Sparrow: The problem has emerged because of the abuses conducted by the Syrian government, attacks on medical personnel and infrastructure. Then it spreads – the issue with what's unfolding in northern Iraq and other neighboring areas is that diseases have no respect for borders. Polio has already crossed into Iraq, both in officially recorded cases and in those that have gone unrecorded.
A key problem is that refugees  get stigmatized for carrying diseases like this, and that means they don't want to approach doctors or international organizations and present the illness.
There was a little girl near the Iraq border diagnosed at one year old, last November. And there was stigma. The girl's twin was sent away, and then she was shunned by everyone in the village because they were deathly afraid they would catch polio from her. So all people can perceive is the negative effect of presenting the illness – they think that they'll get shunned, stigmatized.
Polio continued into 2014 in Syria  and then spread into Iraq, which raises questions about the campaign that was being done by Unicef and the WHO in the Middle East. The Syrian government should be declaring a national polio emergency – which of course they haven't. This would mean they would have to vaccinate all long-term visitors and residents and to make sure all visitors or residents planning international travel are vaccinated, which is difficult with refugees.
Polio is especially hard because you need to administer six shots in total. The Turkish government has been fantastic trying to vaccinate refugees at the border and in camps, but you need six [vaccines] in a row, and it's hard to track people.
Measles is a one-shot inter-muscular vaccine. Polio in conditions like these is an oral vaccine, dropped over several rounds, and has to be done door-to-door in order to keep track of patients and be effective.
Syria Deeply: How has the transient refugee situation  impacted the spread?
Sparrow: They're very contagious, polio and measles – there are 2.5 million refugees registered, and there have to be another 1 million unregistered. They end up living in squalid conditions with people who are not fully vaccinated. For example, a refugee comes into Iraq from Syria and ends up living like that in places like Anbar, and then is displaced to Baghdad, and could be carrying a virus.
A lot of people forget that polio is never easy to diagnose. It's not like one day you're running around and the next day you have paralysis. And it generally affects young children who can't walk yet anyway.
Syria Deeply: How deep is the stigma today, and can anything be done to combat it?
Sparrow: There is such stigma to having polio in this region. The last indigenous case was in 1995. In 1999 there was a case, but it was imported and not an endemic case. Once polio's back in the country, and you've got clinical polio, you've lost the battle. What Syria needs, and now Iraq too I expect, is not just vaccines, it's tech support. WHO has provided some good tech support, telling the local workers how many vaccines they need, how many children could he affected.
But now you need to harness the expertise of MSF or people with medical expertise, and connect them well with the local Syrian and Iraqi NGOS with the networks and access and ability to be on the ground. They need to know how to decontaminate water. They need to know that rubella is devastating if you get it when you're pregnant, because you get the most appalling deformities in the fetus.