Students for Global Health UCL
Don’t Touch The Water: 2022’s chaotic cholera resurgence
“We have now dedicated 70% of our beds to cholera cases.” – director of the only public
hospital in Akkar, northern Lebanon, the poorest part of the country, October 2022.
“The wells and streams are already contaminated…Corpses are floating in the floods.” –
president of the Nigerian Medical Association warning of the spread of waterborne diseases following deadly flooding that killed 600 and displaced 1.3 million, October 2022.
“Only God knows my pain.” – mother of a 22-year-old Haitian man who died after contracting cholera amid a desperate humanitarian crisis driven by gang warfare and a lack of fuel, clean water and medical supplies, October 2022.
Cholera is an acute infection caused by consuming food or water contaminated with the
bacterium Vibrio cholerae. It is preventable and easily treatable. Yet, since January 2022, 29
countries have reported outbreaks so severe that the WHO has suspended its two-dose
vaccine strategy and started rationing supplies. 13 of these countries did not have outbreaks last year.
“We try to avoid it but we don’t always have a choice,” explains a mother in Bebnine,
northern Lebanon. Here, her family must grow produce, well aware that the water used to
irrigate their crops comes from a man-made dark brown stream likely contaminated with
cholera. Lebanon suffers chronic electricity shortages that have disrupted water supplies and sewage treatment plants. On 6 October, cholera returned for the first time in thirty years. 80% of the population lives in poverty and with a collapsed lira, food and medicine supplies are running thin – one man was desperate to get his daughter treated: “They wouldn't take her unless we paid two million Lebanese lira. What should we do? Steal? Kill? We don’t carry arms. We are poor.”
Cholera can kill in a day. It is often linked to poor sanitation and insufficient access to safe
drinking water. Consequently it is endemic to the poorest parts of the world. Malawi, where
over half the population live in poverty (and 20% in extreme poverty), has been battling a
cholera outbreak since April following torrential rains and floods triggered by tropical storm
Ana and cyclone Gombe from January to February. The 80% of Malawians whose
livelihoods depend on agriculture are extremely vulnerable to natural disasters and climate
change – as of 1 November, over 6,000 cases have been reported and 183 people have
died of the disease.
With an incubation period of 12 hours to five days, cholera causes severe acute watery
diarrhoea and dehydration. Since the bacteria can be found in the faeces of those infected
for up to 10 days (even in the asymptomatic) and be shed back into the environment,
cholera can spread rapidly. Referring to the epidemic in Syria (where MSF suspects over
13,000 cases), the WHO reported that the outbreak started in June in Afghanistan, then
spread to Iran, Iraq, Pakistan, and war-ravaged Syria. Deadly floods in northern Cameroon
this year exacerbated an existing outbreak with at least 17 dead (as of 19 October) though
the toll in “difficult-to-access” villages is feared to be much higher. A public health official
warned that the disease is spreading fast in countries around the Lake Chad basin including Nigeria where thousands of cases have been reported. The governor of Cameroon’s Far North has implored civilians to use new community toilets and not to drink from flooded streams – he added that humanitarian workers are helping people consume cooked food, boiling water and following good hygiene to reduce infections, particularly amongst children. More ominously, however, he explained that workers cannot reach many conflict-prone areas due to the threat of the ongoing Boko Haram insurgency.
Though cholera is especially virulent, it is easily treatable through prompt use of oral
rehydration solution (ORS). An adult patient with moderate dehydration may need up to six
litres on the first day. Those with severe dehydration (at risk of shock) can be given
appropriate antibiotics while children under five respond well to zinc. The key, therefore, is
ready access to supplies and fast treatment, assets that are dangerously limited in
warzones. Just over a decade since UN peacekeepers introduced the disease to Haiti’s
largest river “via sewage runoff at their base”, this year, the Caribbean nation was supposed
to be declared cholera-free. As of 29 October, nearly 2,000 cases and at least 40 deaths
have been reported, with many observers blaming the eruption of brutal gang wars that have disrupted imports, infrastructure, public services, and transport. More than half the 29
countries in question are suffering from conflict and instability.
Climate change, poverty, and war.
From 2017 – 2021, less than 20 nations reported a cholera outbreak, but according to the
WHO’s epidemic diarrhoeal diseases lead, the mean case fatality rate last year “almost
tripled compared to the five previous years.” The suspects? Climate change, poverty, and
war. Despite stockpiling nearly 30 million oral cholera vaccines, the WHO has been forced to ration supplies and recommend one dose instead of two severely limiting the protection
provided. Cholera outbreaks are almost always accompanied by other humanitarian crises
and often found in places where “droughts, floods, famines or the threat of violence” are
endemic. In Somalia, amid widespread malnutrition, bloody conflict, and an “escalating”
drought, cholera cases in the first six months of 2022 exceeded the total number last year. In Pakistan, struck by devastating floods earlier this year, “access to safe water and sanitation remains limited, with people using contaminated water for household consumption,” according to a WHO doctor – outbreaks of malaria, diphtheria, dengue fever and measles, in addition to cholera, have been reported. Back in Bebnine, Lebanon, three days after his brother died of cholera, a man declared: “We are living in a state of panic, we are afraid of everything now.”
Written by: Omar Khan