Several countries have recently recorded a new outbreak of cholera, particularly low-income countries that suffer from water and sanitation system crises. Cholera is a bacterial disease mostly spread through contaminated water, causing acute symptoms such as severe dehydration, which can be fatal if left untreated. The recent outbreak has raised fears of expanding spread in more countries and of the growing threat of an epidemic amid global concern. Questions have also been raised about the possibility that cholera could pose a new global epidemic risk and about the reasons for its comeback in those countries.
Recently, a cholera outbreak has been reported in several countries. According to Dr. Ahmed al-Mandhari, WHO’s Regional Director for the Eastern Mediterranean, speaking at a November 2, 2022, WHO news conference on the cholera outbreak, eight of 22 countries in the Eastern Mediterranean region and 29 countries worldwide are suffering from cholera. Signs of a cholera outbreak have appeared in some of the following main locations:
1. Increasing cholera cases in Syria: The Syrian Health Ministry first announced a cholera outbreak in Aleppo in September 2022, reporting nine deaths. The UN believes that the cases are linked to individuals who drank contaminated water from the Euphrates River. According to UNICEF statistics, as of November 10, 2022, more than 35,000 suspected cases of cholera had been recorded in Syria. About 2,500 tests were conducted, with only about half of them showing the disease. Meanwhile, the Syrian Health Ministry pointed to 46 deaths "resulting from delay in obtaining medical advice," to quote the director of communicable and chronic diseases, who also fixed the total number of confirmed cases at 1,249.
2. Confirmed cases reported in all Lebanese governorates: The Ministry of Public Health in Lebanon reported the first case to the WHO on October 6, 2022. According to Lebanese Ministry of Public Health statistics, as of November 10, 2022, there were 3,160 suspected and confirmed cases. The total number of confirmed cases was 511, with 18 deaths from the disease. While the cholera outbreak was initially confined to the northern areas, the epidemic quickly spread, according to the WHO office in Lebanon, and confirmed cases have now been reported in all eight of Lebanon’s governorates. Lebanon’s Minister of Health, Firas Al-Abyad, said that most of the cholera deaths were the result of not receiving the necessary medical care.
3. Cholera resurgence in Haiti three years after it was contained: Three years after Haiti was able to contain a cholera outbreak that began in a UN peacekeeping camp in 2010, the disease reappeared in October 2022. On October 25, Haiti’s Ministry of Health reported that the cholera outbreak was spreading rapidly, with the number of cases doubling to about 2,000 within a few days, with at least 41 deaths. The marked rise in the number of cholera cases in Haiti is causing concern among health officials and organizations, given the limited ability to treat cholera patients, with only 350 beds available in cholera treatment centers in the country.
4. Fears of a cholera outbreak spreading from Malawi to neighboring countries: Since March 2022, Malawi has been experiencing a new outbreak of cholera—the largest in the country in ten years. The outbreak coincided with Tropical Storm Anna and Cyclone Gombe, which battered the country in January 2022 and March 2022, respectively. Subsequently, Malawi experienced floods that displaced residents and left them unable to access safe water and sanitation. The total number of cholera cases in Malawi reached 6,056, including 183 deaths, from March 3 to October 31, 2022, amid fears that cases will rise during the rainy season in November.
The WHO considers the risk of further spread of the disease to be very high at the national and regional levels. Confirmed cases were reported across the border in Mozambique during the initial period of the current outbreak, and a cholera outbreak was also reported in late September in the Lago district of Mozambique, which borders Malawi. The hardest-hit regions in Malawi are located in the northern part of the country, some of which are on the borders with Tanzania and Zambia, with major movement across borders in the region with neighboring countries and beyond. All this—in addition to the history of cross-border spread of cholera—prompted the WHO to warn of a cross-border epidemic outbreak, and it called on Malawi and neighboring countries to coordinate on the issue.
Several driving factors contribute to the current wave of cholera outbreaks in some countries, including:
1. Ongoing conflict in Syria and destruction of infrastructure: Cholera usually spreads in densely populated communities whose water and sanitation infrastructure is damaged, particularly in fragile and failed states, due to administrative failure, political conflict, or even natural disasters or lack of resources. Thus, the cholera outbreak in Syria is largely linked to the 11-year-old conflict in the country, in which approximately 7 million people remain internally displaced and more than 2 million still live in camps.
Reports indicate that living conditions in most of these camps are substandard, with very limited access to basic water and sanitation services, and that most of the water and sanitation infrastructure in the country is either damaged or neglected as a result of the ongoing conflict. For example, the UN notes that more than two-thirds of water treatment stations, half of pumping stations, and one-third of water towers in Syria have been damaged. Meanwhile, Syrians rely mostly on water shipped by truck or buy water that is pumped from untreated water sources, which leads to further risk of contamination and provides a ripe environment for the outbreak of cholera in Syria.
2. Negative impact of Turkey’s regional policies: International and human rights organizations note that Turkey bears significant responsibility for exacerbating the spread of cholera in Syria, by seizing water from the Euphrates River and preventing its flow from the Alouk water station to the city of Hasakah and its countryside. While the Alouk water station— which is located in the city of Ras al-Ayn (Serê Kaniyê) in the northern countryside of Hasakah and is controlled by Turkey and its affiliated armed Syrian opposition factions—is the sole source of water for Hasakah and its countryside, Turkey and its factions have cut off the water coming from the station to Hasakah and its countryside more than once since capturing the city in 2019.
Turkey has also held the waters of the Euphrates within its territory since 2020, which has led to the stagnation of Euphrates River water and created an environment suitable for the multiplication of disease-causing bacteria and viruses. In October 2022, the UN attributed rising cholera cases in Syria to the severe reduction in Euphrates water levels, drought-like conditions, and use of unsafe water sources.
3. Lebanon’s economic crisis and institutional paralysis While Lebanon had been free of cholera since 1993, the country’s current economic and political context has provided a suitable climate for the outbreak of disease in the country. Public services are in the fourth year of a grinding economic crisis, and a political crisis has paralyzed state institutions. According to the Center for Infectious Diseases Research at the American University of Beirut Medical Center, Lebanon suffers from a chronic inability to deliver clean water and electricity to homes and camps, which leads to further problems in wastewater treatment and disposal.
UNICEF notes that refugees and Lebanese families with tight finances are forced to rely on contaminated water sources due to lack of sufficient pipelines and the high cost of private alternatives. Accessing adequate supplies of clean tap water is difficult due to the disruption of distribution systems and widespread electrical outages amid Lebanon’s energy crisis. Pumping and filtration stations have shut down, and a sector of Lebanese question the safety of tap water when it does flow. At the same time, high rates of inflation have led to three- to five-fold price increases for bottled water over the past year, putting it out of reach for most Lebanese with high poverty rates.
4. Difficulty accessing safe water sources in the Philippines: Cholera cases in the Philippines have increased greatly during 2022. The Ministry of Health recorded 4,102 cases of cholera from January 1 through November 2, 2022, an increase of about 254%, compared to the corresponding period last year, which saw only 1,159 cases. Likewise, 37 people died of cholera from January 1 to November 2, 2022.
The cholera outbreak in the Philippines is primarily due to the population’s reliance on unsafe water sources. Despite its growing economy, the Philippines faces major challenges in terms of access to water and sanitation. The WHO notes that 10% of Filipinos are unable to access safe water sources, and the organization water.org points out that more than 3 million people in the Philippines are still dependent on unsafe water and unsustainable water sources, and 7 million lack access to improved sanitation.
5. Violent Haiti gang activity impedes medical efforts: Haiti suffers from complex crises, with the risk of hunger in the country reaching record levels. The violence perpetrated by armed gangs exacerbates the spread and risk of cholera in Haiti. UN spokesman Stéphane Dujarric stated that fuel shortages—resulting from gangs’ blockading the main fuel import station in Haiti—complicate the work of non-governmental organizations, hinder the supply of clean water needed to combat cholera and limit its spread, and also impede the work of medical facilities and threatens to shut them down. The high risk of kidnapping by gangs has prevented aid groups from entering some areas, UNICEF offices have been looted, and shipments of medicine and medical instruments have been blockaded at the port.
6. Shortage of global supplies of cholera vaccine: With the cholera outbreak in several countries, the world is experiencing a shortage of cholera vaccines for various reasons, first and foremost the lack of interest from global vaccine manufacturers in the production and distribution of cholera vaccines. The cholera vaccine is not a priority for manufacturers because with the cheap price of the oral vaccine requires large sales to make a profit and does not motivate major companies to engage in its manufacture and distribution. For example, during 2021, the Indian company, Shantha Biotechnics—which is affiliated with the French company, Sanofi, which produces about 15% of the oral cholera vaccine, Shanchol—announced that it will stop producing the vaccine by the end of 2022, and will stop distributing it by the end of 2023.
While the South Korean company, EuBiologics, is looking to increase production in the coming years, and other companies, such as the Indian companies, Hilleman Labs and Bharat Biotech, cooperate to produce and distribute the cholera vaccine, those operations may need quite a bit of time, especially with some estimates indicating that the processes required to produce and distribute new cholera vaccines will take about four to five years. Thus, the WHO announced plans to temporarily provide only one dose of cholera vaccine, instead of the two-dose regimen, due to the shortage.
7. Increasing potential for the spread of cholera due to climate change: Climate change increases the chances of cholera spreading. Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO, confirmed the link between climate change and health crises, pointing out that climate change leads to an outbreak of cholera, as confirmed by other medical reports. Climate change leads to an increase in the occurrence of environmental disasters such as hurricanes, droughts, and floods that reduce the ability to access clean water. For example, with the emergence of a cholera epidemic in Kenya, the Kenyan Ministry of Health warned that its drought, which has reached a level unprecedented in 40 years, could worsen the spread of cholera in the country.
In conclusion, there are a number of heightened risks raised by the cholera outbreak, including, for example, mounting pressure on the Lebanese health system. Lebanon’s economic crisis and institutional paralysis has created an environment that spurs the spread of cholera, and the outbreak of the epidemic may lead to further pressure on health care facilities that already have difficulties due to a shortage of staff, funding, and medical necessities, amid warnings of an outbreak that exceeds the number of available beds and the capacity of Lebanese hospitals. In addition, at the societal level, the outbreak of cholera in Lebanon raises concerns about the escalation of hate speech against the estimated 1.5 million Syrian refugees in Lebanon. Lebanon’s Samir Kassir Foundation has observed an increase in hate speech against Syrians since the emergence of cholera in Lebanon last October, especially given the widespread governmental and popular belief in Lebanon that the cholera outbreak in the country is linked to its outbreak in Syria last September.