Cholera, which had disappeared from Lebanon for three decades and one from Syria, last November crept into the home of Huda Izzedin in Arsal, a town in Lebanon’s Bekaa region, about 15 kilometers from the border with Syria. “I’m sure it was at a wedding two weeks ago because there were a lot of people there,” says the 21-year-old mother in the living room of the house, while her mother-in-law, Mariam, takes care of little Wael, who is still struggling recovered from vomiting and contracted the disease when she was only six months old. However, cholera is not usually spread through contact with the crowds, but rather through consumption of water or food contaminated with the bacterium Vibrio cholerae, so it most likely got into the well water for which they pay around £800,000 a month ( today around 11 euros, in the volatile exchange rate of the country).
Huda defines it as “the cleanest around” and the owner as “someone you trust,” but the water wasn’t treated and nobody had checked its quality. In a poor area where the state, which has plunged into a brutal economic crisis since 2019, is unable to ensure cleaning, sanitation and sewage treatment, locals drink, wash and cook with water from up to 6,000 public and public Well private, explains Hussein Zreiq, health coordinator in Lebanon for the NGO Relief International. “It’s almost impossible to know where it’s coming from in each case and which ones are contaminated,” he laments.
Cholera is the umpteenth bane of these two countries that are going through difficult days, especially Syria, which is stringing tragedies together. And most likely, the latest — the earthquake that killed nearly 6,000 in the country on April 6 — is making the outbreak worse. The World Health Organization said in an email that health organizations “have reviewed their projections of cholera transmission [en Siria] assuming a higher rate in the coming months” in the earthquake-affected areas. The low winter temperatures are helping to slow the deterioration, but the problems caused by the earthquake – such as damage to sanitation infrastructure, crowds and the difficulties for displaced people to wash and get drinking water – mostly point loudly in the opposite direction to the climate getting warmer, WHO adds. In addition, according to the UN Humanitarian Affairs Office, the earthquake damaged 37 medical centers in the area and forced 20 to cease operations.
Hussein Zreiq visits the Syrian refugee tents in Arsal.Diego Ibarra Sánchez
In countries with poor sanitation systems and problems accessing water, natural disasters usually lead to a resurgence of the disease, as in Haiti after the 2010 earthquake. This is all the more true given that the hardest-hit part, the Northwest, concentrated more than half of the population 88,000 possible cases and 101 deaths registered by Syria between the start of the epidemic (last August) and last January 28th. The trend has been declining, partly due to the two million doses of oral vaccines administered between December and January in the four hardest-hit provinces. Just as a new vaccination trial had begun, the earthquake struck.
After almost 12 years of war that has claimed half a million lives, left 90% of Syrians in poverty and displaced more than half the population from their homes (about 6.6 million displaced abroad and a similar number displaced within the country water), most rely on water purchased from tankers or from untreated sources. Two-thirds of the water treatment plants, half of the pumping stations and a third of the water towers have already been damaged by the conflict.
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The disease emerged in neighboring Lebanon last October. “It is not clear how the first cases started, what is certain is that it happened because the water and sanitation conditions in Lebanon are not adequate. Basically, cholera is a question of access to sufficient water, hygiene and sanitation. The Lebanese also buy some of the water they consume, which is also usually not chlorinated and could also be contaminated, so the spread of the disease could come from any of the affected communities,” explains Ibrahim Mustafa Chico, Water and Sanitation Coordinator by Action Against Hunger, an NGO that distributes hygiene and disinfection kits to refugees and applies a chlorine solution to kill bacteria in collection wells and latrines.
Here, in the Arsal border region, an estimated 70 to 80 percent of private wells are contaminated, whether by agricultural products or faeces, explains Mustafa Chico. And since the wastewater is not treated, the bacteria end up underground.
Refugee tents in Arsal.Diego Ibarra Sánchez
Cholera apparently came to Lebanon from Syria. Zreiq believes by groundwater feeding wells on both sides of the border. Water infrastructure never fully recovered from 15 years of civil war (1975-1990), but the state now doesn’t even have enough fuel to run the water treatment plants, which have mostly been shut down.
According to the country’s health minister, Firass Abiad, the main victims of the outbreak in Lebanon are Syrian refugees. 1.5 million people live in Lebanon. In Arsal, as a result of two major population movements in 2013, they survive in informal tent settlements. One as a result of the Battle of Qalamun, a mountainous region seen across the border. And another due to the advance of regime forces and its allied Hezbollah militia towards Al Qusair. Most refugees now work as seasonal workers in quarries or in agriculture, explains Zreiq. It rains and floods form at the entrance to the camp, a risk factor for the spread of cholera.
below the need
Before the eruption, Syrians in the camp received 7.5 liters of water per person per day, which in a month is equivalent to one of the tanks that – along with tires and some antennas or solar panels – top the roof of the tents. After the outbreak, it has increased to 35, 40% of family needs. “Typically, a person’s water consumption in a developed country is almost 200 liters per person per day. However, during acute humanitarian crises, particularly when the displaced population is from an urban context, the number drops to around 70 or 80. Below this threshold, populations begin to demonstrate poor hygiene and sanitation practices, favoring the potential spread of the disease. Even before the crisis, all communities had problems with access to water, but in the last year the situation has only worsened due to cuts in funds due to the conflict in Ukraine,” Mustafa Chico laments.
Most of those affected hardly notice that they have cholera, with symptoms such as leg cramps or mild diarrhea. However, about 20% develop severe diarrhea or vomiting, which can lead to dehydration. In these cases, a rehydrating treatment is sufficient. But in vulnerable populations and contexts where accessing adequate medical treatment is difficult, cholera becomes deadly, especially for children.
One of the biggest challenges is awareness. When asked about the precautions they take to avoid contagion, some refugees respond as if cholera is an esoteric disease or a secondary concern compared to the suffering they carry. Maamun Tawil, 42, admits he doesn’t know where the water he, his wife and their three children drink comes from. And Fuaz, who is two years his senior, boasts that he is one of the few who not only uses chlorinated water for drinking and cooking, but also for tea. “As tastes change, a lot of people here do it with regular water,” he says with his 11-year-old son Hussair. Humanitarian workers avoid entering homes where they suspect infection to avoid being singled out or shunned by their neighbors. They simply clean the common areas, the latrines, the surrounding garbage dumps, and educate the entire community, regardless of whether they have tested positive.
An employee of the NGO Action Against Hunger works to disinfect the camp because of cholera. Diego Ibarra Sanchez
Despite the difficulties, Lebanon has managed to contain the outbreak with 23 deaths. Data from the Ministry of Health last Wednesday shows a huge improvement, which appears to be due to the massive oral vaccination. Of the total of 6,576 cases between suspicion and confirmation, only 14 are from the last 24 hours and hospital admissions have fallen sharply. With Lebanon and Syria not the only victims but part of the largest pandemic in a decade (30 countries affected), there are no vaccines for everyone (it is a disease of the poor) and the population is getting a single dose of two in a timely manner It is estimated to protect for six months.
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