Naisreen Gharib accompanies her ailing daughter, Vien Aziz, in a cholera ward at the Sulamaniyah Teaching Hospital in northern Iraq. (Photo by James Palmer)

SULAMANIYAH, Iraq — The Kurdistan region of northern Iraq has withstood the destruction of its villages and deadly gas attacks at the hands of Saddam Hussein. Now, as the semi-autonomous Kurdish government strives to increase its independence, the region is coping with another adversary: a cholera epidemic.

One of the areas hardest hit by the recent outbreak of the infectious disease is Sulamaniyah, a province of nearly 1 million people in the northeast corner of the Kurdistan region, straddling the Iranian border.

Local health officials here said at least 1,041 people have been infected with the cholera bacterium since late August.

Azad Faraj, a microbiologist in Sulamaniyah's public health laboratory, said the recent outbreak is from a strain common throughout the Middle East and previously seen in Iraq. While officials have yet to pinpoint the source, all indications point to contamination of the province's water supply.

With a water shortage throughout the province and no sewage treatment plant, Sulamaniyah is fertile ground for the propagation of the intestinal disease, which is commonly contracted by drinking water that has been contaminated with human feces.

"Every few years we face an epidemic," said Dlair Maroof, 34, a physician at the Sulamaniyah Teaching Hospital, the primary care center for cholera patients in the province.

According to a recent survey by Sulamaniyah's water directory, the province is meeting only 27.5 percent of its water demand. Some officials here fault the regional government, saying it failed to upgrade the basic infrastructure to meet the requirements of a burgeoning population of Iraqis seeking the safety and stability the region offers.

Farhad Sabin, Sulamaniyah's water director, said that while the city's population has skyrocketed 65 percent since 2003 to nearly a million people, Kurdistan's central government has ignored his pleas to overhaul the province's water networks.

Sabin added that people here are digging wells and using suction pumps in an effort to access water — possibly accelerating the spread of cholera.

"During the dry season, some parts of the ground have a higher concentration of sewage than water," he said. "The entire water system needs to be overhauled."

The province is making some moves to increase the supply of clean drinking water. A project is under way to pump 280,000 cubic feet of water per hour from the Dokan Dam 40 miles west, along with the construction of additional water storage tanks.

Meanwhile, the Sulamaniyah Teaching Hospital struggles to cope.

Maroof, the physician, said the hospital was obliged to establish an admission center specifically for potential cholera cases. The number arriving daily peaked at 250 on Sept. 10, but has since fallen to between 70 and 90.

In a room crammed with about 20 beds, doctors and nurses scurried one day last month to attend to the steady flow of arriving patients, while other patients were shuttled out.

Jamal Ishmael, 35, a secondary school teacher, brought her 32-year-old sister, Samira, to the center after she began to show symptoms of infection. "We're afraid it's cholera," Ishmael said as her sister lay on a bed, curled up under a blanket and softly moaning.

Shukrya Mahmoud, 35, and her two daughters, Madia, 20, and Soleen, 17, were preparing to return home after a few hours of rehydration at the Sulamaniyah Teaching Hospital. "We had been vomiting for three days, but now we feel better," Mahmoud said.

Maroof noted the water shortage in the region is compounded by the lack of public health education. "When clean drinking water is not available, people are most likely going to find it from a source that is not sanitary," he said.

According to the World Health Organization, a 132-pound person requires at least two liters of clean drinking water daily, and one liter daily is necessary for a 22-pound child, though those amounts vary depending on climate and individual activity.

Most of those hospitalized in Sulamaniyah for symptoms of cholera said they regularly drink water from their household taps, and some living outside the city said they dug their own wells or used suction pumps to draw water.

Khalaf Sala, a 40-year-old toy vendor who earns an average of $10 per day to support his wife and five children, said he can't afford to purchase the bottled water in the market — a five-liter container runs around a $1.50 — and has never considered boiling water from his tap.

Sabin, Sulamaniyah's water director, makes daily trips to the local hospital to learn more about where the recently infected people come from. Then he visits the area to sample groundwater in an effort to pinpoint the source of the province's latest cholera outbreak.

Still, with no scientific verification to this point, the 52-year-old civil engineer remains skeptical that the source is groundwater.

"Everyone is blaming the water, but there's no proof yet," Sabin said as he displayed a sheaf of papers documenting his ongoing survey of the area.

There was little doubt, however, inside the women's ward for cholera at the Sulamaniyah Teaching Hospital.

Vien Aziz lay motionless on her back with an intravenous tube running into her left arm. Her other hand delicately rested on her stomach as her 55-year-old mother, Naisreen Gharib, lingered anxiously over her bedside.

"I've been drinking water from inside the house," Aziz, 27, an administrator at Sulamaniyah University, said. "From now on I'm going to buy it from the store."

TOMORROW: An Iraqi radio station finds refuge in Kurdistan after repeated attacks.

About the author.

(Many interviews for this report were conducted through a translator. James Palmer wrote this article for The Star-Ledger of Newark, N.J. He can be contacted at j_palmer(at)stratosnet.com.)