American University of Beirut (Lebanon) Cholera Spread: a symptom of structural failures

A position statement by the Department of Health Promotion and Community Health at FHS, AUB

Lebanon has been cholera-free since 1993. That changed on October 6, 2022, when the Ministry of Public Health reported two laboratory-confirmed cholera cases in the country’s northern region. Since then, the numbers of cases and deaths have increased at an alarming rate. Cholera outbreaks are also reported from other countries in the region. Cholera is an acute diarrheal infection caused by ingestion of food or water contaminated with the cholera bacterium.  It is strongly connected to inadequate sanitation.

Lebanon’s response to the cholera outbreak has been far from addressing the root causes of the epidemic. The government launched an emergency appeal requesting support from the international community to procure vaccines, medicines, and water test kits. Citizens and refugees in the country began to receive information through various media outlets on how to wash their hands and how much chlorine to add to their water tanks. Yet, without addressing the underlying causes of the spread of cholera – old and dilapidated water and sanitation systems, and water privatization – behavioral interventions will have limited if any impact in stopping the epidemic. By focusing on individual-level solutions, people and communities with limited resources are called to bear the responsibility of managing and controlling the outbreak instead of the state institutions, international organizations and those concerned with water and sanitation.  For years, researchers have been raising the alarm about the poor water quality in Lebanon, especially in refugee settlements and impoverished areas of the country. In the context of an economic crisis, political deadlock, and dwindling humanitarian funding, it is not surprising that access to clean water and sanitary services has deteriorated for a considerable proportion of the population, creating a fertile ground for the spread of cholera.

Cholera epidemics are signs of structural deficiencies; historically, cholera is an outcome of failed systems and services. This type of failure is a violation of the human right to safe water and sanitary conditions, which is felt by the general public. On October 26, residents in a southern urban center in Lebanon protested severe water shortages, highlighting the urgency of addressing their demands to access uncontaminated public water supplies in light of the rapid spread of cholera. It is time for those who hold decision-making power to come to this realization as well.

To mitigate cholera, we do not need innovation. Instead, we need to learn from history – that the sanitation movement was critical to improving public health – and to go back to basics. No human being, whether citizen or refugee, should be deprived of the right to clean water and a healthy environment. Promoting individual hygiene behavior change – the only public health action undertaken by the State at this point while waiting for adequate number of vaccines to arrive – will only narrowly contribute to limiting the spread of transmission. Unless the government and high-level decision-makers actively work towards urgent waste water management, upgrading the public water supplies in Lebanon, the cholera outbreak will not be contained. Based on the above, we call on the government, municipalities, and UN agencies to direct urgent resources to maintain, repair, and operate the water treatment plants.