War and the weaponisation of water are driving cholera epidemics

New cases of cholera, an acute diarrhoeal illness caused by toxigenic strains of Vibrio cholerae, disproportionately occur in resource-limited settings with poor water and sanitation hygiene (WASH) infrastructure. In some countries like Bangladesh, the disease is considered to be endemic, with climate change-associated heavy rains leading to seasonal outbreaks.

Elsewhere, however, drivers of the water-borne epidemic can be traced to man-made disasters, including conflict and forced migration. Such is the case currently in Syria, a country entering its twelfth year of a conflict that has led to the destruction of water treatment facilities and health systems.

This is not the first time Syria has confronted a cholera epidemic. In 2009, an epidemic in two north-eastern governorates which infected over 1,000 people, remained unacknowledged by the Ministry of Health until 2015. That year, a second epidemic, which was attributed to an outbreak occurring in neighbouring Iraq, emerged in the context of concurrent epidemics in the country, which included polio, typhoid and hepatitis.

''It is not a coincidence that cholera is emerging in numerous countries in the Middle East, a region in which protracted conflict and political turmoil have produced the world’s largest number of forcibly displaced persons. Identifying and responding to public health emergencies in such settings is extremely challenging, as capacity for surveillance within fragile health systems is further diminished during crises.''

This current outbreak, with over 13,000 suspected cases and at least 60 deaths, like the one seven years ago, is the direct consequence of war and the weaponisation of water infrastructure. Prior to the conflict, approximately 95% of Syrians had access to clean water. Following the destabilisation of over half of the country’s WASH infrastructure, that figure has been reduced by over 40%, as an estimated 14.6 million Syrians today lack reliable access to safe water. In addition to the deliberate destruction of wastewater treatment facilities, the attrition of engineers from the technical workforce has precluded adequate maintenance, thereby worsening water insecurity.

These challenges more recently have been acutely exacerbated by climate change, leading to drought threatening the Euphrates river, as well as the Russian invasion of Ukraine, which has driven up the costs of water, making it prohibitively expensive for many in Syria.

Water scarcity is most severe in the poorest areas in northern Syria, where residents of internal displacement camps—sometimes dubbed ‘widow camps’—have resorted to drinking from the sewage-contaminated Euphrates river, thought to be the source of the current epidemic.

Syria is not the only country in which war has precipitated a cholera epidemic. Indeed, there are countless historic and current examples of cholera occurring particularly in the context of protracted conflict settings.

The ‘Gulf War Syndemic’, for instance, refers to the synergistic epidemic of cholera, typhoid, measles, polio, and other infectious diseases that occurred in Iraq following the 1991 Persian Gulf War. These devastating epidemics, which led to the excess deaths of over 500,000 Iraqi children in the seven years that followed the war, emerged following the deliberate destruction of WASH facilities and US sanctions which restricted importation of food, water and aid, leading to massive paediatric malnutrition.

More recently, as an unprecedented cholera epidemic persists in Yemen, studies there have found that the number of cases is highest in geographic areas most impacted by the now seven-year conflict. Yemen’s cholera epidemic, described as the worst in modern history, with over 2.5 million cases, was only recently mitigated following a large-scale vaccination campaign, which may be insufficient in the long-term if the conflict there persists, as immunity wanes with time.

It is not a coincidence that cholera is emerging in numerous countries in the Middle East, a region in which protracted conflict and political turmoil have produced the world’s largest number of forcibly displaced persons. Identifying and responding to public health emergencies in such settings is extremely challenging, as capacity for surveillance within fragile health systems is further diminished during crises.

The Syrian National AIDS Program, for example, reported a near-total cessation of HIV surveillance efforts among high-risk populations, while in Lebanon, the majority of HIV testing centres have similarly ceased operations. Insufficient vital registration systems and chronic underinvestment in public health infrastructure, both of which largely predate current conflicts, additionally limit effective public health responses in the region. Furthermore, the fragmentation of conflict-affected countries like Syria may contribute to a lack of political will among authoritarian governments to accurately monitor and report emerging epidemics.

The United Nations has declared the cholera epidemic in Syria ‘a serious threat’ to the region.

I began writing this from my Beirut apartment, shortly after receiving notice of the first confirmed case of cholera in Lebanon since 1993. There have now been over 50 confirmed and suspected cases in the Akkar governorate, a rural, agricultural region from which my family originates and which has suffered from decades of governmental neglect, massive poverty, frequent blackouts, and pollution leading to water scarcity.

.@WHO says there have been more than 15,000 suspected cases and over 60 deaths from #cholera in Syria.

This rise in cases is compounded by severe water shortages, resulting from low levels in the Euphrates, drought-like conditions, and the destruction of water infrastructure. pic.twitter.com/q39OQFlAQw

— UN Geneva (@UNGeneva) October 7, 2022

Lebanon, like parts of Syria, relies largely on privatised trucked water which receives little, if any, quality control oversight. I don’t know how this epidemic will unfold in Lebanon, but I do know that there needs to be a coordinated, multi-sector response that transcends the country’s political and sectarian barriers.

While the lack of epidemiologic surveillance will surely be a challenge, a concerted effort should nonetheless be urgently directed to simultaneously implement a vaccination campaign which prioritises those at highest risk, such as impoverished Lebanese and Syrian refugees living in rural, border-adjacent areas; localise and decontaminate culprit water sources, particularly those used in irrigation; and ensure that health systems are equipped with the necessary resources to diagnose and treat suspected cases with oral and intravenous rehydration and antibiotics.

Novel data visualisation technology, which have been used in Yemen to produce dynamic maps of cholera transmission, should be leveraged to effectively allocate resources.

The HIV pandemic has taught us that ‘prevention is treatment’, while Covid-19 has shown that infectious diseases do not respect even the most closely guarded borders. These lessons should be applied too, to cholera, a preventable and treatable infection that can be effectively eradicated with syndemic responses from scientists and policy makers alike.

Our lived history has shown that cholera epidemics will continue to emerge at the intersection of conflict and climate change, both of which uniquely impact marginalised and poor populations. In order for us to prevent the next epidemic, a global effort is needed from us, the people, to prevent the next war.

Dr. Sasha Fahme is a physician and global health researcher who lives and works between Beirut, Lebanon and New York City, USA. Her research focuses on the syndemic impact of conflict and forced displacement on women's health in humanitarian settings.

Follow her on Twitter: @SashaFahme

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