Lebanon has been cholera-free since 1993. On October 6, 2022, that changed when the Ministry of Public Health reported two laboratory-confirmed cholera cases in the country’s northern region. Since then, the numbers of cases and deaths have increased at an alarming rate. The current situation according to the Lebanese Ministry of Public Health website on November 21 shows 20 cumulative deaths and 4,008 suspected and confirmed cases, 25 percent of which are among individuals 4 years of age and below. Cholera outbreaks are also reported in other countries in the region, including Syria and Iraq. Cholera is an acute rapidly dehydrating diarrheal infection caused by the ingestion of food or water contaminated with the bacterium Vibrio cholerae. It is strongly connected to inadequate sanitation.
Lebanon’s response to the outbreak so far has included launching the government’s emergency appeal requesting support from the international community to procure vaccines, medicines, and water test kits. The World Health Organization (WHO) secured 600,000 doses of cholera vaccine from the International Coordination Group to vaccinate all refugees and host communities aged 1 year and above. On a local level, residents received information through various media outlets on how to wash hands and mixed messages about how much chlorine to add to their water tanks.
Unfortunately, this response has been far from addressing the root causes of the epidemic. Without addressing the underlying causes of the spread of cholera – old and dilapidated water and sanitation systems, and water privatization – behavioral interventions will have limited, if any impact in stopping the epidemic. By focusing on individual-level solutions, people and communities with limited resources are made responsible for managing and controlling the outbreak, instead of state institutions and international organizations. Overcrowding, and unsanitary living conditions in jails have long been root determinants of different types of infectious outbreaks globally since the 1800s, as have refugee camps and informal settlements.
Decades of dirty water
For years, researchers have been raising the alarm about the poor water quality in Lebanon, especially in refugee settlements and impoverished areas. The country lacks a national wastewater strategy, leaving it up to local municipalities with limited resources and know-how. At the same time, rivers and lakes have been dumping grounds for industries for years. In 2021, UNICEF cautioned based on a focused study that the water situation in Lebanon is on the brink of collapse. Despite the large number of studies and consultations commissioned to resolve the water pollution in rivers, lakes and water bodies in Lebanon, very little has been achieved.
In the context of an economic crisis, political deadlock, and dwindling humanitarian funding, it is not surprising that access to clean water and sanitary services has deteriorated for a considerable portion of the population. The public sector water provides about three million people with water but considering the energy crisis, a large number of the population and one million refugees rely on alternative sources like water trucks, or private sources. This has created a fertile ground for waterborne diarrheal diseases to emerge, given that a major source of contamination is microbiological. This includes cholera. Cholera epidemics are signs of structural deficiencies; historically, cholera is an outcome of failed systems and services, which is a violation of the human right to safe water and sanitary conditions.
To mitigate cholera, we do not need innovation. Instead, we need to learn from history – that the sanitation movement was critical to improving public health – and to go back to basics. No human being, whether citizen or refugee, should be deprived of the right to clean water and a healthy environment. Promoting individual hygiene behavior change – the only public health action undertaken by the state at this point while it waited for adequate number of vaccines to arrive – will only narrowly contribute to limiting the spread of transmission. Unless the government and high-level decision-makers actively work towards urgent waste water management, upgrading the public water supplies in Lebanon, the cholera outbreak will not be contained.
However, there is nothing so far in the government discourse which is showing any commitment to work on the systemic failings. We call on the government, municipalities, and United Nations’ agencies to direct urgent resources to water treatment plants and utilize the expertise already available in academic institutions to provide environmentally sound solutions, and prevent future outbreaks of other types of waterborne diseases. Improved water supply interventions alongside a focused cholera vaccination program are proven to be more likely to yield favorable public health outcomes than just a vaccination program alone.