Settling with danger: conditions and health problems in peri-urban neighbourhoods in Aleppo, Syria

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2005 17: 113Environment and UrbanizationF Hammal, J Mock, K D Ward, M F Fouad, B M Beech and W Maziak

in Aleppo, SyriaSettling with danger: conditions and health problems in peri-urban neighbourhoods

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Environment&Urbanization Vol 17 No 2 October 2005 113

ENVIRONMENTAL CONDITIONS, SYRIA

Settling with danger: conditionsand health problems in peri-urban neighbourhoods in Aleppo, Syria

F Hammal, J Mock, K D Ward, M F Fouad, B M Beech and W Maziak

SUMMARY: In the Eastern Mediterranean region, mass rural-to-urban migra-tion and uncontrolled population growth in low-income countries such as Syriahave given rise to sprawling unplanned peri-urban development. Virtually no dataare available on the environmental conditions and health status of residents of suchcommunities. This paper describes formative qualitative research in eight settle-ments in informal zones around Aleppo, Syria’s second-largest city, to assess envi-ronmental problems and health hazards. Several common themes emerged regardingcommunity-level conditions that placed residents at substantial health risk, includ-ing sub-standard housing, limited access to high-quality health care, an absence ofadequate essential services, problems with toxins and pollutants, poor educationaland employment opportunities, and crime. Further research is being conducted tounderstand the distribution of these problems and the associations between en-vironmental conditions and health status. Urgent action is needed to eliminatedangerous living conditions in these settlements.

I. INTRODUCTION

RURAL-TO-URBAN migration has risen dramatically in many parts of theworld, including the Eastern Mediterranean region, where cities have expe-rienced population explosions over the last two decades. This phenome-non has given rise to large makeshift settlements around major urbancentres.(1) Typically, these peri-urban areas are unplanned and provide resi-dents with poor housing and inadequate services. These adverse conditionscreate community-wide hazards such as unsafe water, poor sanitation andair pollution, exposing residents to a host of adverse health effects.(2) Despiterapid peri-urbanization and environmental degradation in most major citiesin the Eastern Mediterranean region, most countries still lack reliable datawith which to make informed policy decisions about environmental prob-lems within these settlements.

Aleppo (Halab) is one such city. Aleppo is the longest continuouslyinhabited city in the world, dating back to the early second millennium BC.It grew from its early origins as a major trading hub on the “Silk Road” tobecome the modern administrative and economic centre of northern Syria.The current population is estimated at 2 million inhabitants, or about aquarter of the Syrian population.(3) Since the 1970s, Aleppo has absorbedwaves of migrants from its surrounding countryside, and its populationhas grown rapidly due to a high birth rate.

Fadi Hammal, MD, is aresearcher and projectmanager at the Syrian Centerfor Tobacco Studies inAleppo, Syria. He will be aHubert H Humphrey Fellowin the Department of MentalHealth, Johns HopkinsUniversity during the2005–06 academic year.

Address: Jubran KhalilJubran Street 56/7, PO Box9636, Aleppo, Syria; e-mail:[email protected]

Jeremiah Mock, MSc, PhD,is a medical anthropologistwho conducts community-based research on healthpromotion. His backgroundincludes research oninternational agriculturaldevelopment, internationalhealth and tobacco control.Dr Mock has conductedhealth social science trainingcourses and research inThailand, Japan, Laos,Cambodia, Indonesia andSyria.

Address: Department ofPsychiatry, 3333 CaliforniaStreet, Ste 465, University ofCalifornia, San Francisco,CA 94143-0848; e-mail:[email protected]

Kenneth D Ward, PhD, isassociate professor in theDepartment of Health andSport Sciences, and interimdirector of the Center forCommunity Health, at theUniversity of Memphis,Tennessee. He also serves asintervention director of theSyrian Center for TobaccoStudies in Aleppo, Syria. DrWard is a healthpsychologist and is involved



Poor and working-class families have tended to settle in clusters at theperiphery of Aleppo, forming haphazard residential areas. Settlers havetypically built housing, shops and small factories without formal approvalfrom the municipal authorities. The scale of these informal settlements issubstantial; the municipality of Aleppo estimates that the 22 major infor-mal settlements occupy about 45 per cent of the city’s inhabited area.(4)

Population densities in these settlements range from an estimated 200persons per hectare to as many as 750 persons per hectare in areas wheresix-storey apartment buildings have been built.

These peri-urban residential areas have rapidly outgrown Aleppo’sprojected plans for expansion. Although the municipality has designatedthe western side of the city as the main area for planned expansion, theinformal zones have proliferated on the northern, eastern and southernsides. The rapid growth of the informal zones has also put a strain on exist-ing municipal resources.(5) In most zones, the municipality has faced chronicdifficulties keeping pace with building basic infrastructure such asasphalted roads, sewage systems, treated water, electricity and telephonelines, or providing services such as policing, schools or clinics.(6) Residentssuffer from unknown levels of exposure to pollutants from garbage dumps,cement plants, tanneries, automobile salvage, unregulated factories andsewer outlets.

Given these conditions, it is highly likely that the inhabitants of theseperi-urban settlements experience a “double burden” of infectious diseasesand chronic non-communicable diseases associated with urbanization andindustrialization.(7) However, little is known about the economic, environ-mental and sociocultural conditions within the communities, or about theenvironmental hazards the inhabitants experience. We therefore conductedthe present study to create the first systematic ethnographic mapping of theenvironmental conditions, health status and needs among the residents inthese communities. Our objectives were to build a basic understanding ofthe conditions and to lay the groundwork for conducting a large-scalehousehold survey. This paper reports on our initial formative qualitativeassessment of perceptions of environmental exposures and health risks inAleppo’s informal zones.

II. METHOD

a. Background

THERE ARE CURRENTLY 22 informal zones registered with the munici-pality of Aleppo. These zones have been growing in the northern, easternand southern fringes of the city, with the western side being the main direc-tion of planned city expansion. The three informal regions in northern,eastern and southern Aleppo have many similar demographic and socioe-conomic characteristics. However, they differ in terms of several importanthealth-related attributes, including level of urbanization and potential expo-sure to certain pollutants. The northern region is regarded as an environ-mental “hot” zone for industries that generate pollutants, including cementmanufacturing, tanneries and car repair, in addition to being the site of thecity’s main garbage dumps. The eastern region is more rural, with manyworkshops and small, unregulated factories scattered between the resi-dences. The southern region contains numerous workshops and factories,including cement plants. Residents in this region are also exposed to biolog-

114 Environment&Urbanization Vol 17 No 2 October 2005


1. Brennan, E M (1999),“Population, urbanization,environment and security: asummary of the issues”, EnvironmentalChange and Security ProjectReport Vol 5, WoodrowWilson International Centerfor Scholars, WashingtonDC, pages 4–14.

2. McMichael, A J (2000),“The urban environment

primarily in tobacco controlresearch.

Address: Center forCommunity Health,University of Memphis, 633Normal Street, Memphis,TN 38152; e-mail:[email protected].

Fouad M Fouad, MD, isintervention coordinator atthe Syrian Center forTobacco Studies in Aleppo,Syria, and general surgeonfor the Aleppo CancerCenter Project.

Address: Aleppo CancerCenter Project, PO Box 246,Aleppo, Syria; e-mail:[email protected]

Bettina M Beech, MPH,DrPH, is associate professorand director of theBehavioral MedicineProgram, Department ofPsychology, at theUniversity of Memphis,Tennessee. Her researchinterests include healthdisparities, childhoodobesity prevention andtreatment, and smokingcessation.

Address: Department ofPsychology, University ofMemphis, Memphis, TN38152; e-mail: [email protected]

Wasim Maziak, MD, PhD, isdirector of the Syrian Centerfor Tobacco Studies inAleppo, Syria, and seniorresearcher at the Institute ofEpidemiology and SocialMedicine in Muenster,Germany. His researchinterests include tobaccocontrol and respiratoryhealth.

Address: Syrian Center forTobacco Studies, PO Box16542, Aleppo, Syria; e-mail:[email protected]



ical pollutants due to their close proximity to the city’s main sewer outletand the practice of irrigating vegetable farms using wastewater from thesewer.

Qualitative methods are being used increasingly in public healthresearch, and they are especially helpful for community environmentalhealth research as they provide a way to produce community narrativesthat give voice to individuals, and characterize the community in a fulland rich fashion.(8) To study environmental risks and the health status ofresidents of Aleppo’s informal zones, we brought together a multidisci-plinary team consisting of experts in medical anthropology, epidemiology,medicine, environmental science, behavioural science and public health.This paper describes the team’s initial formative qualitative work to assessperceptions of environmental exposures and health risks in the informalzones, using behavioural observation, key informant interviews and“doorstep” interviews. Given the exploratory nature of this study, weconducted our research in the tradition of “rapid rural assessment”, butmodified and applied our approach according to the conditions in the peri-urban settlements.(9)

b. Sampling strategy

We used communities as the units of analysis. A community was definedas a distinct residential area within or at the periphery of the city, thatcommunity members recognized as a neighbourhood or district by nameand that had been designated by the municipality as an “informal zone”,meaning that the area had not been officially zoned or planned for resi-dential development. We used a stratified sampling procedure to selectcommunities, to ensure that our sample reflected a cross-section of condi-tions. First, we identified all of the communities in the northern (n=7),eastern (n=8), and southern regions (n=7). Then, we randomly selected twocommunities from the southern region, three from the northern region, andthree from the eastern region, in proportion to the number and size of thecommunities in each area. This resulted in a sample of eight out of the 22communities. The names of the selected communities, and their majoritypopulations, are shown in Table 1.

c. Data collection procedures

As is essential in any applied ethnographic study, we used multiplemethods of data collection. As described below, members of the teamconducted direct observation, key informant interviews and “doorstep”



and health in a world ofincreasing globalization:issues for developingcountries”, Bulletin of theWorld Health OrganizationVol 78, No 9, pages1117–1126; also Smith, K R, JM Samet, I Romieu and NBruce (2000), “Indoor airpollution in developingcountries and acute lowerrespiratory infections inchildren”, Thorax Vol 55, No6, pages 518–532.

3. Central Bureau ofStatistics – Syrian ArabRepublic (2001).

4. Massouh, Z (2000),Housing Policy andUrbanization: NationalPerspectives, Syrian ArabRepublic, Economic andSocial Commission forWestern Asia (ESCWA),United Nations, New York.

5. Chibli, M and S Sakkal(1999), Informal Settlements:Problems and Solutions,report presented to themunicipality of Lattakia,Syria.

6. See reference 4.

7. World HealthOrganization (1999), WorldHealth Report 1999: Making aDifference in People’s Lives,WHO, Geneva.

8. Brown, Phil (2003),“Qualitative methods inenvironmental healthresearch”, EnvironmentalHealth Perspectives Vol 111,No 14, November, pages1789–1798.

9. Scrimshaw, S C M (1990),“Combining quantitative

Table 1: Sampled informal residential areas in Aleppo, Syria

Zone or neighbourhood Region Population

Shek-Said and Salheen Southern Majority Arabs

Ansari Southern Majority Arabs

Ard-Alhamra Eastern Majority Arabs

Baydeen Eastern Majority Arabs

Shek-Khoder and Shek-Fares Eastern Equally Arabs, Kurds and Turkmans

Shek-Maksoud Northern Majority Kurds, with some Arabs and Turkmans

Bani-Zaid Northern Majority Arabs, with some Kurds and Turkmans

Handarat Northern Majority Palestinian refugees



interviews with residents.(10)

Direct observation. Team members explored the conditions in thecommunities by directly observing and documenting the settings andconditions in which people lived and worked. We observed residents indifferent locations engaging in everyday life and producing and experi-encing their culture. We systematically recorded data in field notes,describing the settings/contexts within the settlements, the characteristics,attributes and mannerisms of people/actors within the settlements, andthe processes/activities in which they engaged within those settings. Wealso took photographs in public places and in people’s homes, with theirpermission. To ensure that our observations were not shaped by takinginto account only the best conditions (the “Potemkin Village” phenome-non), we conducted direct observation throughout the communities. Wefollowed the main thoroughfare to “the end of the road,” typically at theedge of the settlement’s expansion where the housing was newlyconstructed, or where squatters were still living in tents.

Key informant interviews. We conducted interviews with key inform-ants who were embedded in their communities to obtain data aboutcommunity characteristics, health issues and needs from their perspec-tives. We used the following criteria to identify potential key informants: • they should be providers of health or social services, and knowledgeable

about the population and setting; and• they should have sufficient experience in the community and access to

information that would allow them to provide a broad picture of thehealth and environmental conditions. Across the three regions, we selected 28 key informants, including four

community leaders, four social workers, four officials from the AleppoDirectorate of Health and the city council, three nurses/health workers, sixphysicians from public primary care clinics, four physicians in private prac-tice and three clinic support staff. Of the key informants, 32 per cent werefemale.

We conducted interviews lasting 1–1.5 hours, following a semi-struc-tured interview guide designed to elicit information on current health-related practice patterns, health care policies in clinics, perceptions aboutthe major health issues and environmental risks experienced by residents,perceived interest of physicians and patients in seeking ways to improvehealth services, perceived barriers, and recommendations regarding prac-tical ways to improve the health care of people living in informal zones. Amedical anthropologist interviewed some key informants with assistanceand interpretation from a public health physician–researcher who wasbeing trained in anthropological interviewing. With other key informants,the physician–researchers conducted the interviews alone.

Doorstep interviews. It can be challenging to conduct extended inter-views in underserved communities, where men tend to be suspicious ofoutsiders and women often stay inside their homes. Our initial experiencesof working in Aleppo’s informal zones indicated that residents could bereluctant to provide personal information or sign official documents(including informed-consent statements). To deal with these conditions,we developed a “doorstep interview” protocol to obtain information fromcommunity members about overall housing conditions, family and socialcharacteristics within the community, and perceptions about health statusand environmental risk factors.

When conducting doorstep interviews, we followed a standard in rapidassessment studies of selecting potential interviewees based on their acces-

and qualitative methods inthe study of intrahouseholdresource allocation” inRogers, B L and N PSchlossman (editors), Intra-household ResourceAllocation. Food andNutrition Bulletin,Supplement 15, UnitedNations University Press,Tokyo, pages 186–198.

10. See reference 8; alsoMaziak, W, T Asfar and FMzayek (2001), “Socio-demographic determinantsof smoking among low-income women in Aleppo,Syria”, International Journalof Tuberculosis and LungDisease Vol 5, No 4, pages307–312; Maziak, W, TEissenberg, R C Klesges, UKeil and K D Ward (2004),“Adapting smokingcessation interventions fordeveloping countries: amodel for the Middle East”,International Journal ofTuberculosis and LungDisease Vol 8, No 4, pages403–413; and Altschuler, A,C P Somkin and N E Adler(2004), “Local services andamenities, neighborhoodsocial capital, and health”,Social Science and MedicineVol 59, No 6, September,pages 1219–1229.





sibility, our intuition about the potentially valuable perspective they mightprovide, and their willingness to participate. In each of the communities,we selected two adult residents from at least two households. Due to theconservative cultural norms in these settlements, all of the doorstep inter-views were conducted with men, typically in a familiar setting at or nearthe front of their homes. Some of these face-to-face semi-structureddoorstep interviews were brief (approximately ten minutes), while otherslasted up to one hour, depending on the interviewee’s availability andinterest in participating.

Interviews focused on the basic features of the households, including theinternal and external characteristics of the dwellings such as the number ofstoreys, the presence of conjoined facilities, the number of people residingin each household, the location of the kitchen, fuel sources for cooking andheating, the presence and capacity of ventilation sources (e.g. exhaust fans,chimneys, windows), the presence of smokers in the households (both ciga-rette and waterpipe smokers), the location and timing of smoking, the exis-tence of barriers to pollutants (e.g. smoking restrictions, door separatingkitchen from the rest of the household), and proximity to outdoor sourcesof air pollution (e.g. factories). Particular attention was given to commu-nity characteristics and activities that may be associated with indoor airquality and respiratory health. Community members were asked to sharetheir knowledge, perceptions and opinions about the conditions in theircommunity, based on their day-to-day living experience and circum-stances.(11)

d. Data analysis and synthesis

We analyzed data using content analysis and grounded theory – an induc-tive process by which themes are identified in the data, and theory subse-quently developed or modified, without being driven by a priorihypotheses. Standard ethnographic techniques were employed to recordand transcribe data, and a two-stage process was used to synthesize andanalyze it. In the first stage, two investigators independently read the orig-inal transcripts and reviewed other materials to identify themes that werecentral to areas of discussion both within and across each class of inter-viewee (key informants or community members). By reading and study-ing raw data (observational field notes, verbatim transcripts, photographicimages), team members used the process of content analysis to identify theliteral and symbolic significance of content within these data sources. Theinvestigators analyzed these data to identify meanings that the participantsintended to convey, looking at the data on three levels of significance: theactual literal meaning, the sub-text (what is implied but not stated overtly),and the supertext (larger themes or ideas to which the data are referring orare connected). Through this process, we labelled data and constructedcategories using endogenous typologies. Additionally, we used the itera-tive constant comparative method, an analytical process of comparing newdata as they are collected to existing data, to identify recurring patterns.The investigators discussed their independent interpretations of the dataand then jointly decided upon a final coding scheme of relevant themes.Passages in the transcripts’ comments were categorized according to thesethemes, to determine both the range and the significance of relatedresponses. In the final stage, the investigators synthesized the findingsfrom the data within and across groups.



11. Ensign, J (2004),“Quality of health care: theviews of homeless youth”,Health Services Research Vol39, No 4, Part 1, August,pages 695–707; alsoValentine, N B, A de Silvaand C J L Murray (2001),“Estimating responsivenesslevel and distribution for191 countries: methods andresults”, GPE DiscussionPaper Series No 22 WHO,accessed free athttp://www3.who.int/whosis/discussion_papers/pdf/paper22.pdf; and Strauss,A and J Corbin (1990),Basics of Qualitative Research:Grounded Theory Proceduresand Techniques, SagePublications, NewburyPark, CA.



III. FINDINGS

a. Overview

GENERAL CONDITIONS IN the informal zones. In general, the commu-nities in the informal zones have populations ranging from approximately5,000 to 108,000. Most communities have been built incrementally over thelast 15 years, with houses and apartment buildings laid out on a gridpattern. All of the structures are built very close together, allowing theminimum street area necessary for vehicles. Some reach six storeys high,while others are single-storey stone houses. Streets and narrow alleyways,many of which have only a cobblestone or dirt surface, are dusty in thesummer and muddy in the winter. Often during the daytime, the streets arefilled with children playing, people shopping, occasional herds of goats,and motorcycles, taxis and minivans weaving in and out. At night, thestreets tend to be empty except for occasional vehicles.

Ethnic and religious composition. Many residents of these peri-urbancommunities are immigrants from nearby villages, or have moved from onesection of the city to another. Some have come from hundreds of kilome-tres away to settle around Aleppo. The ethnic groups living in these areasare primarily Arabs, Kurds and Turkmans. Ethnic distribution varies withinthe communities, and many are recognized as being populated predomi-nantly by one ethnic group. According to one key informant in the south-ern region of the city, the population of Salheen is composed entirely ofArabs, whereas that of Bani-Zaid is 75 per cent Arabs and 25 per cent Kurdsand Turkmans, and that of Shek-Maksoud 85 per cent Kurds and 15 percent Arabs and Turkmans. In one community located in the northern region,Handarat, the majority of residents are Palestinian refugees. Throughoutthe informal zones, most residents are Sunni Muslims. One reason behindthe geographic differences in ethnic distribution may be because of consis-tent migration from specific villages of origin and concentrations of fami-lies in specific zones.

Children and education. Key informants stated that the populationgrowth rate in most communities was very high. We observed largenumbers of children in most neighbourhoods, playing in the streets, in themud or around garbage and trash. Public elementary schools andmadrasas(12) are located throughout most of the communities. Even thoughelementary education is mandatory and inexpensive, key informants andresidents perceived truancy to be a major problem. Poverty and sociocul-tural factors affected school attendance in many ways. Although publiceducation costs relatively little, many parents were not able to afford theassociated school expenses such as books, stationery and uniforms. Also,because child labour laws are weak, many parents made their childrenwork – often in hazardous conditions such as unregulated factories – to helpwith living expenses. Although many families sent their girls to school,some conservative families, particularly Arabs, did not let their daughtersattend school after the age of 11–14. This was common practice if the schoolwas more than a short walking distance from the home, which was notunusual for middle schools and high schools.

Employment. Many key informants and residents said that jobs withinthe communities were scarce, and that many men were unemployed. Mentypically worked in dirty and hazardous conditions, such as “cottage indus-try” factories, auto repair shops, and agriculture and livestock. The unem-ployed male residents we interviewed were motivated to take whatever



12. Madrasas are Islamicreligious schools.



jobs were available, which often included low-paying public sector jobssuch as municipality work and day labouring. Women were typicallyexpected to be housewives, although some did work in low-paying jobssuch as cleaning. Some illiterate older women found menial work in facto-ries, and a few educated younger women worked in professions such asnursing. For all residents, obtaining employment outside the informal zoneswas often difficult because of the lack of reliable transportation.

Health care access. Syria has a national system of publicly fundedprimary health care clinics that are available to all citizens regardless offinancial means. These clinics provide basic services such as prenatal care,child vaccinations, dental care, paediatrics and adult internal medicine forchronic disease management. However, health service coverage in thesecommunities is marginal, and ethnic, cultural, educational, institutional andeconomic barriers have hindered effective health care. Almost all the keyinformants stated that neither the quantity nor the quality of these centreswas adequate to address the significant health needs of people living in theinformal zones, where one or two small centres served many thousands offamilies. For example, in Shek-Maksoud, where one health centre located inthe formal part of the area serves more than 1,000 inhabitants, one inter-viewee said: “People do not trust public health services because of the quality ofservices.” Another reported: “We usually go there only for vaccination.” Thissentiment was echoed by another key informant, a physician in a privateclinic in Shek-Khoder, who said, “People usually prefer not to go to the publichealth centres, unless obliged to do so because of their poverty.”

Throughout the middle-class and affluent neighbourhoods of Aleppo,private health clinics are available to those who can pay, and providespecialized and more comprehensive services. In the informal zones,however, very few physicians are willing to operate private clinics becausemost residents lack the means to pay. Also, health care providers perceivethe informal zones as being somewhat dangerous areas in which to work,and most avoid doing so if possible.

Pharmacies. We observed that small pharmacies were more numerousthan health clinics (public or private) in informal zones. Pharmacies oftenserve a dual role, both dispensing medication and providing treatment forsome diseases. In these communities, it is relatively common for residentswho are sick, or who have a sick family member, to consult a pharmacistdirectly, rather than a physician, as pharmacists do not charge as much forexaminations as private clinics, and pharmacies are generally not crowdedand stay open late in the evenings. Unfortunately, pharmacists are notalways well enough qualified to diagnose diseases or prescribe appropriatemedication. Some key informants, especially physicians, claimed that phar-macists sometimes treated diseases inappropriately, and thereby delayedproper diagnosis and recovery.

Shops and vendors. In general, informal zones lacked a sufficientnumber of retail shops to make consumer goods, including food, easilyaccessible to residents. Fresh fruit and vegetables were often difficult tocome by, and residents had to travel outside the informal zones in order topurchase food, clothing and other essentials. The small shops that did existin informal areas were haphazardly located and often unclean.

Security and policing. In general, these zones suffered from an absenceof adequate policing, and very few police stations were located there. Thisappeared to contribute to the residents’ perception that the informal zoneswere unsafe, especially at night, because of drinking and drug use. Manykey informants talked about incidents of meddling, theft, burglary in homes







and workshops, fighting and stabbing. One physician in Shek-Khoder said:“In my clinic, it is common to see a wounded man due to a fight or a stabbing.”Key informants also talked about the perpetration of so-called “honourcrimes”, in which a woman is killed by her family members because sheallegedly engaged in premarital or extramarital sex. One key informantsaid: “I’ve heard many times about women being killed by their families.”

Social assets. Despite the grinding poverty in the informal zones, somecommunities appeared to be remarkably resilient and self-reliant. Somehave existed for over 25 years, and several residents reported living in thesame neighbourhood for more than 18 years. Several communities hadestablished social support networks, particularly in the outer margins ofthe settlements where the population densities are lower. Some communi-ties were close-knit, with neighbours feeling that they could rely on eachother and enjoying spending time together as part of a “big family”. Resi-dents in such neighbourhoods were often relatives or from the same village,and often shared a common goal of improving living conditions for all.

b. Environmental conditions

Physical infrastructure. The road, water, sanitation and electricity systemsin the informal zones were generally unreliable and of poor quality.However, infrastructure was not uniformly poor across all informal zones,or even among neighbourhoods in the same community. For example,Shek-Maksoud, in the northern region, had been connected recently to theelectricity grid but lacked asphalted roads, a piped potable water supplyand a reliable sanitation system. In contrast, Shek-Khoder, a community inthe eastern region, had been connected to the electricity grid, receivedtreated water from city lines, and had had a reliable sanitation system fornine years.

The development of basic infrastructure was usually a gradual processin the informal zones. Typically, new residents staked out a small parcel ofunincorporated public land and started building houses, thus expandingthe settlement’s perimeter. Often, in the early phases of expansion, new resi-dents laid makeshift clay sewer pipes and covered them with dirt andsometimes cobblestones to form streets and alleyways. Many of these areaswere not connected to the municipal sanitation system and lacked adequatesewage disposal, resulting in sewage from underground sewer lines spillingonto open land and into creeks and gullies.

Nearly all houses in all zones obtained electricity from the municipalelectricity company lines. Initially, nearly all recently constructed houseswere connected illegally to high-voltage electrical lines; later, often afterseveral years, they received legal connections regardless of whether or notthe government had officially approved the construction of the homes.From doorstep interviewees, we learned that in the more established neigh-bourhoods, residents had pooled their money and designated a leader tonegotiate with electricity company officials to have the utility place polesand lines throughout their neighbourhood.

Some neighbourhoods were able to persuade the municipality to installwater mains, supplying treated water to metered junction boxes. House-holds then laid steel lines from the meters to their homes. Neighbourhoodsthat were less successful on this front had to find water from other sources.For example, while we were conducting observations in an outlying area ofShek-Maksoud in the northern region, a man drove by on a farm tractorpulling a large tank. A doorstep interviewee (male, head of household)



reported: “We buy water from this water tank trailer, and we don’t know thesources of this water.”

Physical waste collection/disposal and exposure to environmentalwaste. While provision for garbage collection varied considerably betweenand even within zones, in general garbage was a pervasive environmentalhealth hazard. Inadequate garbage disposal has several negative healthconsequences, including the spread of diseases such as leishmaniasis (seebelow), and the creation of unsafe and unhealthy playing environments forchildren, thus exposing them to illness and injury. Residents universallyreported that the garbage problem was enormous and chronic. In the infor-mal zone neighbourhood of Bani-Zaid, we observed that several house-holds disposed of garbage in a common courtyard area where children wereplaying. At the edge of another settlement, across the dirt street from homes,we found mixed food scraps, plastic bags, cans, bottles, animal carcasses,razorblades and other household waste in spent tins and plastic sacks. Insome communities, residents and garbage collectors dumped the garbagein open heaps at the periphery of the settlements, where it was strewnaround by stray dogs, goats, scavengers and children. In other communi-ties, the municipality provided large dumpsters in a designated location,but residents told us that typically these were overflowing. Residentsreported that the city would occasionally send a bulldozer to clear the trash,and there was a perception that adequate garbage disposal was a sharedpersonal, public and government responsibility. A resident in Bani-Zaidcomplained: “We have done our part for the responsibility to solve the garbageproblem, but we need the municipality to help us by fulfilling its responsibility.”Although the lack or absence of services is the greatest contributor to theproblem of unsanitary garbage management, we found that many residentslacked a basic awareness of the dangers, and had limited motivation to curbthe spread of garbage in inappropriate places. A young adult resident inAnsari asked with disappointment: “Nobody cares about the garbage, not theresidents or the municipality. What should I do?”

Industrial waste was common in the informal areas, but types of wastediffered substantially across areas. For example, Salheen and Shek-Said,located in the southern zone, and Handarat, in the northern zone, are inclose proximity to cement factories. Numerous interviewees cited thesefactories as the major environmental problem in their areas, and residentswere worried about respiratory tract allergies and asthma. As a physicianin Handarat said: “There is an increasing number of patients with allergicdiseases like rhinitis and asthma.” In Bani-Zaid, in the northwestern area,textile factories and their wastes were the main problem. Residents alsoexpressed concerns about environmental degradation from smaller work-shops that were common in many neighbourhoods. These environmentalthreats included vapour from melting lead workshops in Salheen, dust fromconcrete-making workshops in Shek-Maksoud, the smell and industrialwaste from shoe-manufacturing workshops in Shek-Khoder and Salheen,gases and foul odours from furniture-spraying workshops and car repairworkshops in Shek-Fares, and waste from dyeing workshops and plasticfactories in Ard-Alhamra.

Housing conditions. Housing in the informal zones was variable, butwas generally of poor quality across the areas and within most neighbour-hoods. Residences ranged from tents, to small houses made of mud bricksor stone, to six-storey concrete and brick buildings. A not insignificantnumber of individuals were living in tents and caves, often having recentlysquatted on a parcel of land, and were planning to build a house. At the





other extreme, many people were living in six-storey tenement-style apart-ment buildings, some of them 30 years old while others were underconstruction. Apartments typically had a small living room and one or twosmall bedrooms, with a separate kitchen and bathroom. People moving intothe city and living in tents, or moving out of high-density buildings oftensettled in neighbourhoods with 1–3-storey houses built of stone, cementand plaster. Most of these homes consisted of one or two rooms with a sepa-rate kitchen and bathroom in which up to 13 family members lived. Someof the poorest families lived in one-room houses with an attached combinedkitchen/bathroom.

Concern about the quality of living conditions differed widely. Somehouses were clean, painted, decorated and well ventilated, while otherswere unclean, unpainted and badly ventilated. Regardless of the type ofstructure, almost all had been built without architectural plans or adher-ence to minimum engineering safety standards. Many structures were builtincrementally (i.e. floors added over time as resources became available)without proper reinforcement. Many of these households also functionedas places of business, including industrial workshops, retail shops and live-stock production.

Heating. The most commonly reported heat source in informal zonehomes and shops was diesel fuel. Diesel is also very common in formalareas of Syria. Due to the great variability in the quality of diesel heaters(prices range from less than US$ 10 to more than US$ 400), the pollutioneffects (diesel leakage, combustion, ventilation) vary, and any ill effects arelikely to affect disproportionately the poorer strata of society. Most of thediesel heaters seen in the informal zones were of moderate to low quality.A sizeable minority of informal zone residents reported using woodstovesfor heating because of their lower cost (since wood often can be collected atno cost), and the perception that wood is a healthier heating source thandiesel. A head of a household in Shek-Maksoud said: “Wood is cleaner thandiesel and gives more heat.”

Cooking. In the informal zones, as in formal areas, the most commoncooking fuel is propane, a cleaner fuel source than wood or diesel, whichcan expose adults and children to dangerous gases and hydrocarbons.However, several household characteristics may influence the safety of evenpropane, including the quality of the stove, ventilation capacity and theplace where cooking takes place (for instance, when cooking in a one-roomhouse takes place in the space where children usually play, the risksincrease).

c. Major health problems

Several common themes relating to health issues emerged across zones andacross interviewee type (key informant and doorstep), as outlined below.

Leishmaniasis (“Aleppo boil”). Leishmaniasis was observed to be acommon problem(13) in most visited zones, for example in Shek-Maksoud,Salheen, Shek-Said and Handarat, where sewage lines are open. A youngman with Aleppo boil on his face said; “It is common here, especially amongkids because they play in the garbage.” The pathogen of this parasitic infec-tion is Leishmania tropica, the vector is the female sandfly, and the mainreservoirs for this organism are rodents. The initial lesion of cutaneous leish-maniasis is a red plaque at the bite site, usually on exposed skin (extremi-ties and face). This lesion enlarges slowly to form multiple satellite nodulesthat coalesce and ulcerate. There is usually a single lesion that heals spon-



13. Ashford, R W, J A Rioux,L Jalouk, A Khiami and CDye (1993), “Evidence for along-term increase in theincidence of Leishmaniatropica in Aleppo, Syria”,Transactions of the RoyalSociety of Tropical Medicineand Hygiene Vol 87, No 3,May–June, pages 247–249;also Tayeh, A, L Jalouk andS Cairncross (1997),“Twenty years of cutaneousleishmaniasis in Aleppo,Syria”, Transactions of theRoyal Society of TropicalMedicine and Hygiene Vol 91,No 6, November–December, pages 657–659.



taneously, causing a scar in patients with reasonably good immune systems.However, if the cell-mediated immunity does not develop, the lesion canspread to large areas of skin and can contain enormous numbers of organ-isms. The drug of choice for treatment is sodium stibogluconate, but resultsare frequently unsatisfactory. Prevention involves protection from sandflybites using netting, window screens, protective clothing and insect repel-lents.(14) Poverty and poor housing conditions in the informal areas hindereffective prevention of leishmaniasis.

Tuberculosis. Many key informants noted that TB has been increasingin the last few years in some areas, for example in Shek-Maksoud, Salheenand Shek-Khoder. Perceived risk factors include poor housing conditions,the high densities within households, and illiteracy and lack of awarenessabout disease transmission. Free government-sponsored TB treatment isavailable in Aleppo to all diagnosed individuals. However, only one diag-nosis centre exists, and transportation difficulties, perceived poor qualityof medical care, and long waiting times for appointments are barriers totreatment. Although the treatment is totally under the supervision of thehealth centres in the first two months, appropriate completion of the treat-ment over the following four months is not assured.(15) These barriersappear to interfere with the successful management of TB in the informalzones.

Cough, upper respiratory infections and diarrhoea. These conditionswere described by most key informants as “the usual winter and summerdiseases,” reflecting the pervasiveness of these health problems in the infor-mal zones. Children were thought to be especially vulnerable as a result oftheir playing outside, near garbage. One interviewee in Shek-Maksoud said:“When kids play outside in the garbage they get cold, and they go back into housesto warm, where the difference in temperature makes them start coughing.”

Injuries. Injuries also particularly affect children, who by and large lacksafe outdoor areas in which to play. A man in Bani-Zaid said: “Recently, aboy was playing around a big hole in the factory construction site, when he felldown the hole and broke his skull. People found him dead two days later.”Another cause of injury might be industrial waste, to which children areoften exposed, including tin, nails, trash, glass and chemicals. Injuries alsooccur indoors. A nurse in Shek-Khoder commented: “The quality of housesand absence of any safety codes like stairs, and roofs without any fences, makechildren vulnerable to injuries from falling.” In addition, the high populationdensities, with children forced to play in the streets, make car accidents acommon health problem. A physician in Shek-Khoder commented: “Chil-dren grow up in the street…and the street is their playground.”

Genetically determined health problems. Genetically determinedchildhood health problems, such as apnea of prematurity and birth defects,are fairly common in the informal zones. The risk of these problemsincreases with consanguinity,(16) which occurs more commonly in the infor-mal zones compared to formal zones. Several factors may increase the like-lihood of consanguinity in the informal zones, including prevailing socialnorms, illiteracy and poverty.

Childbirth at home. Home deliveries, assisted by midwives, werecommon in the informal zones, due to both economic and religious factors.Delivery at home is much less expensive than in a hospital. In addition,norms among conservative Muslims in the informal zones dictate that it isinappropriate for a man, including a physician, to view a woman’s body.Reliable data about neonatal and maternal health outcomes from homedelivery in Syria are lacking. However, several studies in low-income coun-



14. Levinson W E and EJawetz (2000), MedicalMicrobiology and Immunology(Lange Series), Appleton andLange, San Francisco, 582pages.

15. World HealthOrganization (1998),Tuberculosis Handbook,accessed free at http://www.who.int/docstore/gtb/publications/tbhandbook/PDF/WHO98_253-en.pdf;also Vassall, A, S Bagdadi, HBashour, H Zaher and P VMaaren (2002), “Cost-effectiveness of differenttreatment strategies fortuberculosis in Egypt andSyria”, International Journal ofTuberculosis and Lung DiseaseVol 6, No 12, December,pages 1083–1090.

16. Consanguinity ismarriage between first-degree relatives. See Tamim,H, M Khogali, H Beydoun, IMelki, K Yunis and NationalCollaborative PerinatalNeonatal Network (2003),“Consanguinity and apnea ofprematurity”, AmericanJournal of Epidemiology Vol158, No 10, pages 942–946;also Sueyoshi, S and ROhtsuka (2003), “Effects ofpolygyny and consanguinityon high fertility in the ruralArab population in SouthJordan”, Journal of BiosocialScience Vol 35, No 4, pages513–526; and Stoll, C, YAlembik, M P Roth and BDott (1999), “Parentalconsanguinity as a cause forincreased incidence of birthdefects in a study of 238,942consecutive births”, Annalesde Genetique Vol 42, No 3,pages 133–139.



tries indicate that lack of access to emergency obstetric care is a risk factorfor increased mortality and morbidity among both mothers and infants.(17)

Substance use and abuse. Although the use of alcohol and illicitpsychoactive drugs is assumed to be generally low in Syria,(18) there wasevidence that it might be substantial in the informal zones. For example, inShek-Maksoud, one of the key informants said: “Drunk young people anddrug users, and the absence of a police station, make the zone unsafe at night.” Aphysician in Shek-Maksoud said: “Drug abuse is common here, especiallycentral nervous system stimulants”, and another physician commented:“Drug use is frequent and I know two men who died from overdoses.” An inter-viewee in Shek-Khoder commented: “It is more acceptable among Kurds todrink alcohol than among Arabs and Turkmans, because of religious reasons.”These comments suggested that substance use might be more prevalent ininformal zones than in Syrian society as a whole, but was likely to varysubstantially according to the ethnic and religious characteristics of theneighbourhoods.

Tobacco use. Tobacco use is very common throughout Syria, with ciga-rette smoking rates near 50 per cent among men and 10 per cent or moreamong women, according to several convenience samples drawn fromvarious sub-populations (e.g. teachers, physicians, primary care patients).(19)

According to key informants, smoking was very common among men inthe informal zones. One informant estimated: “Seventy per cent of the men inShek-Khoder smoke, and the smoking percentage among women is high too”;another said: “Everything pushes you to smoke – family, friends, work en-vironment and lack of education.” One physician in Shek-Maksoud said:“Smoking is very common here, so I see a lot of cancer and ulcer cases.” Weobserved smokers smoking with their children in the same room, suggest-ing that there was little awareness or concern (especially among peopleolder than 30) about the health effects of secondhand smoke on children.One physician said: “ETS (environmental tobacco smoke) has no meaning intheir minds, so they easily smoke everywhere in the house.” Although this lackof awareness is not unique to the informal zones, it appeared to be verycommon there. Although narghile (waterpipe) smoking is also common, andgrowing, in Syria, with approximately 25 per cent of men reporting regularuse,(20) according to our observations and key informant reports, narghileuse seemed to be much less common than cigarette smoking in the informalzones. A physician in Shek-Maksoud reported: “Waterpipes are less commonbecause it needs time and mood.” A similar comment was made by an inform-ant in Ansari: “Waterpipe smoking is less common because it is connected withluxury and needs more time to prepare and smoke.”

IV. CONCLUSIONS

SQUALID URBAN LIVING has become a reality for many people in low-and middle-income countries throughout the world. Unfortunately, manycities are being overwhelmed with exploding poverty and environmentalhealth problems because of alarming increases in rural-to-urban migration,uncontrolled population growth, and the failure to respond adequately tothese trends. Studies have shown that the quality of provision for sanita-tion and water in settlements in low-income countries can be strongly asso-ciated with health outcomes.(21) In the Eastern Mediterranean region,including Syria, the haphazard proliferation of unplanned settlementsaround and within major urban centres, and with no support for infra-



17. Wagle, R R, S Sabroe andB B Nielsen (2004),“Socioeconomic andphysical distance to thematernity hospital aspredictors for place ofdelivery: an observationstudy from Nepal”, BMCPregnancy and Childbirth Vol4, No 1, page 8; also Davies-Adetugbo, AA, S E Torimiroand K AAko-Nai (1998),“Prognostic factors inneonatal tetanus”, TropicalMedicine and InternationalHealth Vol 3, No 1, pages9–13.

18. David H Jernigan (2001),Global Status Report: Alcoholand Young People, WorldHealth Organization,Geneva; also UnitedNations Office on Drug andCrime (UNODC) (2004),World Drug Report, Volume2.

19. Maziak, W (2002),“Smoking in Syria: profileof an Arab developingcountry”, InternationalJournal of Tuberculosis andLung Disease Vol 6, No 3,pages 183–191.

20. Maziak, W, S Rastam, TEissenberg, T Asfar, FHammal, M E Bachir, M FFouad and K D Ward(2004), “Gender andsmoking status-basedanalysis of views regardingwaterpipe and cigarettesmoking in Aleppo, Syria”,Preventive Medicine Vol 38,No 4, pages 469–484.

21. Mock, J, L Jarvis, AJahari, M Husaini and EPollitt, (2000),“Community-leveldeterminants of childgrowth in 24 Indonesianvillages”, European Journalof Clinical Nutrition Vol 54,Supplement 2, pagesS28–S42.



structure, is becoming an increasingly serious and urgent public healthproblem.

In Aleppo, Syria’s second-largest city, poor people in the city’s manyperi-urban settlements are living with a substantial burden of environ-mental hazard and with the associated deterioration in their health. As afirst step toward developing a comprehensive assessment of environmen-tal hazards in Aleppo’s informal zones, we conducted qualitative forma-tive research to develop an overview of residents’ perceived environmentalrisks and health problems. This study is the first to use ethnographicresearch methods in an international multidisciplinary collaboration forenvironmental health research in Syria. Our experience showed that whilethere are cultural and gender-specific challenges to using these methods inSyria, generally the rapid assessment approach is feasible and worthwhile,especially when funding is limited.

We found that many health problems in these peri-urban settlements arecomplex and are intertwined with the economic and environmental condi-tions and the social fabric of these communities. Through observation andinterviews, we encountered recurring themes relating to the environmen-tal problems that perpetuate poverty, namely: poor housing conditions;limited awareness of risks; restricted employment opportunities that oftenforce residents into hazardous work environments; poor access to qualityhealth care; crime and substance abuse; poor infrastructure support forbasic services such as garbage disposal, clean water and sewage; and expo-sure to environmental hazards, including factory waste, garbage and rawsewage, and poor-quality air. We also found that poor people living in thesevery difficult environmental conditions managed, with limited means, tocreate community survival strategies to cope with some of these conditions.Additionally, we found that Aleppo’s municipal government and agencieshave made incremental efforts to address some environmental health prob-lems, although their efforts still lag far behind the vast and ever-increasingneeds in these communities.

In the informal zones in Aleppo, we found hundreds of thousands ofpoor people settled in dangerous conditions. We also found that these poorpeople were often forced to accept these dangerous conditions because oftheir impoverished circumstances and limited political–economic influence.Addressing the pressing community health needs of these underservedpopulations will require a multi-faceted approach and community–govern-ment partnerships. With the detailed descriptive information we havecollected in this study, we have developed and fielded a population-basedhousehold survey to broaden our understanding of the distribution ofdangerous environmental conditions and their health consequences. Thisapproach will expand the knowledge base from which government officialsand agencies, non-governmental organizations and residents can takesystematic actions to improve the living conditions in peri-urban settle-ments. Aleppo, like many cities in the Eastern Mediterranean region, nowfaces an imperative to dedicate effort and resources to ensure safe settle-ment.





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Settling with danger: conditions and health problems in peri-urban neighbourhoods in Aleppo, Syria

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