Cholera emergency in Lebanon

Published on Sunday 5 February 2023

A light rain falls on the plains of Akkar in the north of Lebanon, the greenest and poorest region of the country. Near the Kfar Melki road, a 20-minute drive from the Syrian border, a truck moves with difficulty along a muddy path that leads to a field lined with greenhouses and shelters. Hearing the clatter of the truck’s exhaust pipe, a group of three Syrian women and about fifteen children approach, intrigued, and are quickly joined by neighbors. The small, soaking wet crowd follows the truck as it pulls into the field next to their homes in the informal camp “Kfar Melki 21”.

Usually, when it rains in Akkar, it is good news for the entire population that subsists off of agriculture, including the dozens of Syrian families who fled the war and work on these vegetable fields. However, since Lebanon recorded its first case of cholera on October 5, 2022, things have changed rapidly.

“When it rains, water collects in front of our tents because we live at the end of the field near the toilets. Although there are pits, the water remains stagnant in many places, and there are about 16 or 17 people using the same toilet,” Nour Zhrahin Dalloubeh, a 28-year-old Syrian woman, tells us.

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“That’s how they all got infected with cholera,” she says, pointing to her two daughters aged six and eight and her three-year-old boy clutching his gray pants. The children suffer from severe diarrhea, vomiting, and fever. However, they are not isolated from the other inhabitants of the camp. On the contrary, they play, a little emaciated, with the children from other families.

The grandsons of Mohammad Hamad Shkar, Nour’s neighbor, have also fallen ill. Mohammad has a thick, black, well-groomed beard, and had told us of his grandchildren’s ailment while we were just a few meters from the water tank that the two families share for bathing, drinking, and washing dishes. “There is a borehole not far from here that we can use when the electricity works. But when there is no electricity, we buy bottled water or water distributed by truck,” explains Mohammad Shkar, pointing to the tank. When you look inside, you find a liquid that looks like anything but clear, clean water.

Access to clean water has become an increasingly urgent issue in Lebanon since October 2019 when the country entered the most devastating and multifaceted crisis in its modern history.

The result is a country on its knees, with public electricity running for one to two hours a day at most. The frequent and prolonged blackouts have interrupted the work of water pumping stations and sewage systems throughout the country, creating conditions that are highly conducive to the rapid spread of the cholera epidemic. The disease is usually contracted from contaminated food or water.

This epidemic, the first in 30 years, spread rapidly among the population of Akkar and the Bekaa, regions that together host 508,755 of the 825,021 Syrian refugees registered in Lebanon by UNHCR. But the virus did not spare the Lebanese population. Patients were quickly hospitalized in Beirut and Tripoli. The World Health Organization (WHO) has since conducted tests on water samples that confirm the presence of cholera throughout the country. According to the Lebanese Ministry of Health, at least 23 people have died since October 2022. Since December, there were 5,600 registered and suspected cases.

“Whenever a case of cholera is identified or suspected, we go to the contaminated area to provide clean, chlorinated water and we disinfect toilets that could have been contaminated by people with cholera,” says Olivier Leconte, SOLIDARITÉS INTERNATIONAL’s country director in Lebanon. The NGO is working on the response to the cholera epidemic in collaboration with local municipalities in the Akkar and North Lebanon regions. We support health institutions, Lebanese citizens, and the Syrian population living in informal camps. “SOLIDARITÉS INTERNATIONAL assists the population precisely where they need it: by tending to the place where the sick person lives and the houses nearby. We also carry out awareness-raising activities and distribute hygiene kits,” explains Olivier Leconte.

In “Kfar Melki 21”, SOLIDARITÉS INTERNATIONAL has deployed a mobile intervention team to explain to residents necessary sanitation procedures that can stop the spread of cholera. “We have to immediately establish what we call a “cordon sanitaire” [quarantine] for the ten households closest in proximity to the infected household,” says Rim Osman, coordinator of SOLIDARITÉS INTERNATIONAL. The deployed team works in collaboration to help the sick: Ahmed, a Program Manager dressed in a blue lab coat with gloves, mask and a shoehorn, signals to Nour and her husband to get rid of potentially contaminated water. He then helps them clean the inside of the tank while another colleague – also wearing safety protection – sprays chlorine on the surfaces of the contaminated houses and those in the vicinity.

Once the area is sanitized, the SOLIDARITÉS INTERNATIONAL team gathers all the families inside the “cordon sanitaire” and distributes leaflets explaining the different ways to avoid the spread of the disease. Two SOLIDARITÉS INTERNATIONAL field workers open the back of the truck and start unloading large white boxes called “Hygiene Kits” to be distributed to the households. Each family receives a basin, a bottle of bleach, soap, disinfection materials and, most importantly, chlorine to purify the water available.

Fifteen minutes by car from “Kfar Melki 21” is the informal camp of “Sammonye 183”, consisting of 17 households & tents, with a total population of 98 Syrian refugees. The pungent smell and swath of flies that greet you as you enter the camp convey the inadequate sanitation conditions. A young woman of 23, Jourieh Hammad, approaches the water tank next to her tent and – while she puts back her pink veil – explains fatalistically: “Water is scarce here.” Jourieh explained that the water tanks are connected to the tents through taps, however there is not enough water for all the families living at the camp. “I need water to wash my children, but the toilets are shared by four or five tents that have at least ten people total.”

Since the beginning of the cholera epidemic, SOLIDARITÉS INTERNATIONAL has been regularly bringing water by way of tankers to provide households in Sammonye 183 with clean drinking water. Water quality is checked by our teams before distribution. In November, SOLIDARITÉS INTERNATIONAL also built four new latrines and four septic tanks. “The situation is much better today. Before, we only had one toilet for almost a hundred people,” says Jourieh, noting that “the camp could use more toilets.” In recent months, her 9-month-old son was hospitalized for rotavirus because of the poor sanitary conditions in the camp. While Jourieh shares her story, other young women gather around her to listen. They nod along and point to their wrists and calves, revealing signs of the rashes that have been flaring up..

Poor sanitation conditions in informal Syrian refugee camps, due to the lack of water, are not uncommon in Akkar. 47 year old Maha Jassem Mohamed who resides at “Minyara 012” confirmed this. About 15 families reside at “Minyara 012”, which is a ten minute drive from “Sammonye 183”. Originally from Hama in Syria, Jassem notes that water is the most critical need at the moment: “Our problems started when Lebanon began cutting power”. As she talks with us in her tent, the excited cries of children outside indicate that the only hour of public electricity available during the day has arrived. Water begins to flow from a tap positioned outside and surrounded by four tents.

Maha picks up a basin and explains that this is the only time when families can fill their pots with water or wash their clothes. “Before, there was a borehole that we used to get water and that was enough, but now, without electricity, we have lost access to water.” SOLIDARITÉS INTERNATIONAL has not yet intervened in this camp. Maha tells the teams that the nearest source of drinking water is the borehole of the neighboring field. They can draw water from the Lebanese owner’s house “when he allows us,” Maha concludes shaking her head.

Several residents of the informal camp “Minyara 012” testify that relations between the camps and the neighboring communities are strained. Some Syrian families have withdrawn their children from school, others report that they have experienced displays of aggression. The few sources of drinking water nearby are not always accessible to “Syrians”, says an elderly woman from a nearby tent.

SOLIDARITÉS INTERNATIONAL’s Country Director in Lebanon, Olivier Leconte, explains the growing hostility from the host population, “The Lebanese are also experiencing great pain and difficulty. The multiple crises that have been going on in their country since 2019, aggravated by COVID, have led to increased poverty.” SOLIDARITÉS INTERNATIONAL faces several challenges: maintaining aid to Syrian refugees, but also supporting affected and vulnerable Lebanese populations,” notes Olivier.

If electricity cuts impact on access to water for Syrian refugees, this is also true for Lebanese throughout the country. Especially for those who live in the poorest region of Lebanon where families are forced to buy drinking water from private companies, as Kamal Mustapha El Selekh, a 39-year-old agricultural worker, explains to us in front of his house in “Kfar Melki”, in Akkar: “The government does not provide water here in “Kfar Melki” and the boreholes are not operational because of the cuts, so we have to buy water supplied by tankers. But we don’t even know if it is drinkable.” This unsecured water is not the only challenge facing Kamal Mustapha and his family. The very high price of water, compared to their income, is also a hindrance. For 1,500 litres, they have to pay LBP 300,000 (about $7) every week. “We can’t afford it,” he says, “but it’s the only solution we have. But now there’s another problem that’s just as serious: cholera.

“I was at work when I suddenly felt dizzy and developed a fever,” Kamal Mustapha El Selekh tells us. “As I started to vomit and experience diarrhea, I decided to go to a primary health center where I was given treatment.” That was mid-November. Two days after leaving the clinic, Kamal received a call from SOLIDARITÉS INTERNATIONAL to inform him that a team would come to his house to take a sample of his water. “A week later, they built a pit at my house. Before it was built, the land and my house were flooded with black water,” Kamal says, pointing to the contaminated water at the end of his yard, overlooking the fields. Of the seven members of his family, only he was infected with cholera.

Once the contaminated areas have been sanitized and the risk of contagion reduced, a major problem still remains. Bebnine, a village in Akkar with a population of 16,000, has become the epicenter of the cholera epidemic. The village’s water source is surrounded by dozens of black pipes made of a plastic similar to that of garden hoses. “These are the pipes that supply water to the houses,” a boy in his twenties tells us as a group of children next to him quench their thirst by filling empty bottles from the aforementioned spring.

An inhabitant of Bebnine, a man in his fifties, approaches the spring and beckons us to follow him down the street about twenty meters away. There, other tangled pipes flow into a canal in the distance. He shows us that some of these pipes are leaking. “These are the sewage pipes that mix with the water pipes,” he says. Since the pipes all have the same black color and disappear into the ground a few meters away, it is difficult to verify which pipes are which. What is certain, however, is that there are studies that have been carried out by the American University of Beirut that reveal the presence of high rates of gastrointestinal diseases among Bebnine residents for the past ten years, and that show the relationship between the quality of the water and the health of the community.

With the support of the World Health Organization (WHO), Lebanon has received 600,000 doses of cholera vaccine from the global stockpile. However, this is not enough to vaccinate all potentially exposed people, given the serious problems with public electricity, access to drinking water, and sanitation of sources. The economic crisis and the Covid pandemic have additionally put a strain on an already compromised Lebanese health system. Even the Minister of Health, Firas Abiad, following a tour of the North of the country a few days after the outbreak of the cholera epidemic, spoke of a general “backsliding of basic services”. In other words, according to WHO, with the migration of health workers, disrupted supply chains, and unaffordable energy supplies, the response capacity of hospitals and primary health care facilities is extremely weakened in Lebanon. “WHO is concerned that this outbreak could overwhelm the Lebanese health system,” said the organization’s director, Tedros Adhanom Ghebreyesus.

In Bebnine, on October 25, 2022, the primary health center “Al Iman SSP” opened a cholera treatment unit twenty days after the first case of cholera was recorded in Lebanon. SOLIDARITÉS INTERNATIONAL actively supported the establishment of the cholera unit by building latrines and garbage cans to collect cholera waste that is then transported by the Ministry of Health to specific landfills. “The first patients we saw here were mainly from informal camps of Syrian people, but today there are more Lebanese infected with cholera than Syrians,” says Dr. Naheed Saadeldin, director of Al Iman SSP. By mid-December, seven people were hospitalized, according to the director. However, she explains that the number of cases can decrease at times and increase at other times depending on the weather: “When it rains, sewage mixes with drinking water, contaminating it”, explains Saadeldin, “because this water reaches families and people use it for drinking and washing food, leading to a spike in cholera cases”.

The center in Bebnine was not the only facility receiving patients affected with cholera. Standing in front of the Abdullah Al-Rassi Hospital in Halba in mid-December, the only public hospital in the whole of Akkar, it is difficult to imagine the confusion that reigned only a month earlier. At the height of the epidemic “the hospital had become an emergency response center, receiving only cholera cases,” says Ali Saada, director of financial administration at Abdullah Al-Rassi, “honestly, we were not fully prepared to cope, and the epidemic also affected the hospital’s workflow in relation to the treatment of ordinary patients.”

According to the administration’s estimations, 500 cholera patients passed through the hospital. Saada tells us this during a tour of the “covid” isolation rooms that were quickly transformed into “cholera” isolation rooms. SOLIDARITÉS INTERNATIONAL built 15 new toilets, 4 showers, and a room for the patients’ dirty laundry. Once we were out of the “isolation” area, Ali Saada pointed out two SOLIDARITÉS INTERNATIONAL operators who were outside, cleaning the hospital’s septic tank and then transporting the cholera-contaminated wastewater to an appropriate disposal site. As the entire hospital structure in Halba also requires more general support, SOLIDARITÉS INTERNATIONAL has built 4 water pumps and 4 wastewater pumps. Saad concluded the tour by saying, “We still need additional support to prepare for any increase in cholera cases.

© Alessandro Rampazzo

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