Water Insecurity & Cholera: Outbreak in the Levant

  • Middle East Policy

    Middle East Policy has been one of the world’s most cited publications on the region since its inception in 1982, and our Breaking Analysis series makes high-quality, diverse analysis available to a broader audience.

Daniella Ciniglio

This essay is part of the MEPC’s Emerging Voices series, highlighting scholarship from rising academics focused on Middle Eastern studies. Author Daniella Ciniglio is a graduate student at the Elliott School of International Affairs at The George Washington University pursuing her M.A. in International Affairs with a concentration in Conflict Resolution.

On October 22, Lebanon observed their first case of cholera in 33 years, spreading originally from its neighboring country, Syria, and quickly catapulting into dozens of cases nation-wide. These recent outbreaks, which are foreseen to escalate, signal a world health crisis and require urgent aid. Cholera, which is usually spread through contaminated water and causes severe diarrhea and dehydration, has been virtually eradicated through widespread introduction of modern sewage and water treatment systems. However, regional conflict resulting in infrastructure destruction, unreliable access to water, worsening socioeconomic status, and climate change has laid the foundation for the rampant spread of cholera throughout Syria and Lebanon.

Due to this disease being virtually eradicated, there is a lack of awareness about how it impacts infected individuals, especially among vulnerable populations at the local level. Although only 1 in 10 of those infected contract severe cholera, shock and rapid death can result when left untreated. Cholera has a short incubation period and symptoms become apparent after usually two or more days of being infected; this complicates the ability to successfully help those infected to recover. Oral rehydration solution (ORS) is primarily administered to those with cholera, but oftentimes it is too late to help if treatment is not readily accessible. Malnourished children and those in poor health are overwhelmingly vulnerable to this illness, with individuals under 14 compromising about 50% of cases.

Notably, suffering countries have not felt a cholera outbreak in over a decade. This year is the first time Syria has seen cases of cholera since 2009; however, the current outbreak surpasses the scale of this former occurrence. With the first cases reported in late August and the outbreak officially declared on September 10, 2022 by the Syrian Health Ministry, cholera has now reached all 14 governorates. 

Susceptibility to the disease is rooted in medical and water-related infrastructure and its ability to provide sufficient living conditions. Within Syria, water sanitation and hygiene (WASH) standards have significantly worsened due to the ongoing civil war, leaving communities reliant on insufficient water supplies. Since Syria has seen large scale damage of proper plumbing and sanitation over the course of the past decade of conflict, it is unable to filter water according to safety standards. Consequently, many civilians have begun to drink water from the Euphrates River, which is increasingly contaminated. According to UNICEF, 42% of the population relies on alternative and unsafe water sources with more than two-thirds of water treatment plants being damaged. 

The Syrian civil war has not only resulted in degraded health conditions but has initiated a mass refugee crisis that exacerbated health problems beyond its borders. This recent outbreak directly led to Lebanon’s first cholera case in October which stemmed from the rural northern governorate of Akkar, an impoverished region that borders Syria. The Syrian refugee crisis has taken a toll on Lebanon by imposing a heavy economic burden that bleeds into increased poverty and lower standards of living, heavy indicators for contracting disease. With a small population of 5 million people in Lebanon, 1.5 million of them are Syrian refugees. Most unofficial settlements and refugee camps house women and children without access to proper health services, water, and sanitation, making them a highly vulnerable group to disease.

Conflict and poverty allow disease to thrive. In Syria, electricity and water have also become weapons of war, as civilians living in crisis zones are facing attacks on their living conditions. The economies of Syria and Lebanon are interconnected, as goods are transported between them and the impacts from shortages of food, water, and medical supplies are jointly felt. Observed with the economic pressure Syria puts on the country and Lebanon’s political and economic deterioration, conditions that lead to the cholera crisis are exacerbated. In the past year, the local currency in Lebanon has lost more than 90% of its value and three quarters of the population have fallen into poverty. Rising oil prices have only worsened the economic meltdown impacting a myriad of societal aspects. 

Access to water is compromised by the lack of reliable electricity and high water prices. Lebanon’s Water Establishments network is relied on by about three million people to provide them with safe bottled water. However, they need hours of reliable electricity to operate pumping stations and provide treatment for water. Additionally, these private operators are affected by fuel prices and shortages which they need for generators and trucks to operate. Currently, around 198,000 Syrian refugees in over 2,000 informal settlements rely on these shipments of clean water. Additionally, the majority of Lebanese households are dependent on bottled water but with their costs soaring, financial burden puts families at risk. 

Along with the devastated infrastructure and economic turmoil, climate change plays a significant role when tracing the spread of disease. The existence of snowcapped mountains that once used to serve as a plentiful water resource for Lebanon can no longer reliably function as so. The snow cover of Mount Lebanon has reduced to 40%, limiting the availability of water and causing droughts of magnitudes never seen before. In Syria, the Euphrates River is suffering low water levels mostly due to rising global temperatures, in turn, progressing bacterial spread. Furthermore, in both countries irrigation systems are impacted as they are forced to use contaminated water to cultivate crops, further increasing the risk of cholera spread.  

While there are long-term reform efforts that must be enacted, international organizations are focused on providing medical aid to those currently impacted. These efforts include distributing single-dose vaccines, monitoring water quality, providing support to hospital care, and strengthening awareness of cholera in vulnerable communities. The International Organization for Migration is currently seeking financial support to maintain its aggressive cholera response in Lebanon, demonstrating the need for international assistance. In Syria, UNICEF is focusing on supporting large-scale rehabilitations of infrastructure and establishing local supply chains to safeguard WASH standards. Cholera’s spread can be minimized, perhaps even halted, by assessing the myriad of core issues — climate change, conflict, and the global refugee crisis — that render Syria and Lebanon vulnerable landscapes to the disease.

  • Middle East Policy

    Middle East Policy has been one of the world’s most cited publications on the region since its inception in 1982, and our Breaking Analysis series makes high-quality, diverse analysis available to a broader audience.

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