In 1993, the last confirmed case of cholera in Lebanon was reported. Thirty years, by traditional standards, is a long time filled with events—both health-related and otherwise—that made us forget cholera. How could we not, with the nightmare of COVID-19 being the most recent? We thought cholera had vanished for good. However, the passage of time does not prevent the recurrence of its events, and here it is rearing its head once again.
The word "cholera" is of Greek origin, meaning a flux of bile (a fluid that aids the body in digestion). The disease is ancient, and some say Hippocrates mentioned it in his writings. It spread globally in the 19th century, claiming millions of lives since. It still affects over 4 million people annually, causing deaths that reach up to 150,000 each year. But let us return to Lebanon. News from Akkar calls for caution: 15 confirmed cases since mid-last week, and projections suggest the actual number is higher. This raises a flood of questions: Why are water institutions not publishing their water test results? Where is the Ministry of Interior and Municipalities regarding the testing of water tanks? Where are the various regulatory bodies overseeing the water used for irrigation in Akkar, the coast, the Bekaa, and the south? Isn't much of it contaminated with sewage, as many fear? These questions have been asked for months, if not years. Only the Scientific Agricultural Research Institute, for example, has sent dozens of letters to the Ministries of Interior and Health requesting water testing. Little has been done, aside from reaching the edge of a new prohibition.
No Response for the Call
Dr. Michel Afram, director of the Scientific Agricultural Research Institute, tells "The Call of the Nation" that the institute has been publishing reports on water pollution across all Lebanese regions and its impact on human health since 2000. These reports have been sent to various officials and parties, but neglect often prevails. Afram adds, “We have been warning that the water is contaminated with sewage, as well as containing heavy metals and chemicals, which will inevitably lead to cases of poisoning, viral hepatitis (jaundice), cholera, and others. It was found in the last officially published report in 2019, just before the COVID-19 pandemic, that 90% of Lebanon's water is indeed polluted. Last May, we issued a statement confirming that water pollution in Tripoli was behind the jaundice cases we witnessed.”
The suppression of warnings regarding the existence of microbial pollutants and the contradiction of water pollution test results are the reasons for our current situation, according to Afram. But let’s go back over two decades. In a meeting of the Public Works, Transport, and Energy Committee in 2000, former committee head MP Mohammad Kabbani mentioned that only 21% of the drinking water that reaches Lebanese homes is clean, and the rest is polluted. At the time, the matter was suppressed to avoid causing panic among citizens, as was said. This merely serves as an example, leading us to a new set of questions: If the water is as clean as we are told, why do diseases and epidemics keep recurring? In which laboratories is water being tested? Are they accredited? Why do the results differ from other state-affiliated laboratories? Are there daily tests conducted, including at the end of each pipeline (i.e., specifically at homes), to ensure no sewage water is contaminating the network? We do not expect answers in this hurry. Let’s continue.
Infection and Symptoms
Dr. Mona Jaradah, a specialist in internal medicine and infectious diseases, reminds us at the beginning of her call with "The Call of the Nation" that we are dealing with a highly infectious case that causes acute watery diarrhea, resulting from consuming food or drinking water contaminated by cholera bacteria. The incubation period ranges from a few hours to five days before symptoms appear. We ask about the latter, and Jaradah responds: “Some patients become infected without showing any symptoms, thus carrying the bacteria and transmitting it for a period ranging from one to ten days. Most infected individuals show mild to moderate symptoms of diarrhea and vomiting, while a minority suffer from severe watery diarrhea, with stools resembling rice water, leading to severe dehydration and possibly death without treatment. The infected individual often feels thirsty, their skin's elasticity decreases, and they exhibit general weakness. Notably, these symptoms often do not come with a fever.”
Here’s how the infection is transmitted: through fecal-oral routes by consuming water or raw foods such as contaminated vegetables and fruits, as well as through dirty hands and inadequately cooked foods. While cholera affects both young people and adults in the same way, children, the elderly, and those with weakened immune systems are at the highest risk of infection and deterioration. In this regard, Jaradah urges: "A suspected or confirmed case should be taken to the nearest health center or seek emergency medical advice for diagnosis, treatment, and adherence to infection control guidelines. Treatment is available at medical centers and primarily consists of serums to replenish lost fluids and necessary minerals, and sometimes antibiotics."
Guidelines That Include Everyone
Moreover, it is essential to note that the guidelines target not only the patient but also—equally importantly—those around them, with the most significant ones being: cleaning and disinfecting toilets and contaminated surfaces with chlorine; ensuring family members have access to clean drinking water, cooking vegetables thoroughly, and avoiding raw consumption; washing hands with soap and water, especially after contact with the patient; maintaining constant cleaning of the patient’s room and using disinfectants for washing their clothes; using double bags for disposing of waste produced by the patient; wearing gloves; not receiving visitors; not sending food from the household with an infected person; and preventing the patient from swimming for two weeks after their illness.
We ask whether a vaccine is available; Jaradah indicates that it is not listed in the vaccination schedule provided to children in Lebanon. Although there are numerous global vaccines against cholera, they are available in limited quantities in Lebanon, which is something the Ministry of Health is currently working to bolster. "If we reach the stage of an epidemic outbreak, the vaccine will be administered. But we need to wait to see who will be prioritized according to availability," she believes.
Sewage System... Stalled
Where is the Ministry of Environment in light of recent developments? Minister Nasser Yassin explained in a chat with "The Call of the Nation" that his ministry is always monitoring the sewage issue, similar to what occurred in Arsal before cholera cases appeared in Akkar, even though the primary treatment remains in the hands of the Ministry of Health. Yassin stressed the necessity of treating wastewater from refugee camps, especially since treatment initiatives have ceased for a period. He continued, "We follow up with the Ministry of Energy and Water and the water institutions, which are the direct responsible parties for managing sewage centers and stations to ensure their operation, as many are stalled, ultimately leading to pollution in rivers, valleys, or the sea." He confirmed that the Ministry of Environment is taking initial preventive measures to prevent pollution in water sources, highlighting its spread across all Lebanese regions and describing the failure to address the sewage issue as a persistent problem needing swift solutions.
And the Crossings Are Unregulated
Even though the primary treatment falls under the jurisdiction of the Ministry of Health, we turn to Minister Dr. Firas al-Abyad, who reiterated in an interview with "The Call of the Nation" that cholera infection is directly linked to sewage issues. Thus, ensuring the safety of the water used by citizens is the starting point: "This is one of the matters we collaborate on with municipalities, as the issue of water and sewage is not solely the responsibility of the Ministry of Health but also that of the Ministries of Energy and Water, while the Ministries of Environment and Agriculture should also perform their roles in this regard."
Al-Abyad considered that the ministry is fully prepared for early detection and surveillance to identify and manage sources of infections to prevent the spread of infection in the community. Additionally, they conduct water tests in the laboratories of public and university hospitals. He reminded that he is keen to provide sufficient quantities of serums, medications, and antibiotics, and to allocate hospital beds for treating cases should they increase, particularly as a rise in numbers is expected due to cholera's rapid transmission.
Identifying the source of the initial infection is the first step in a long journey. Has this been done or confirmed to have come from behind the Lebanese-Syrian borders, especially since Syria has reported over 500 cases with 39 deaths as of last Friday? "As of now, we are still conducting tests and surveillance, and once we receive results, we can more accurately determine the source. The problem lies in the existence of both official and unofficial crossings where many refugees pass to obtain aid from UN organizations. It is not easy to control these crossings, which is a continuous hardship for Lebanon," according to Al-Abyad.
The ministry is working with the World Health Organization to ensure a sufficient stock of medicines, knowing that most cholera cases do not require antibiotics. This is happening in conjunction with necessary precautions and the preparation of hospitals that still maintain a level of readiness following the COVID-19 pandemic. In conclusion, Al-Abyad sends a message to the Lebanese, urging them to adhere to preventative measures and follow the guidelines issued by the Ministry of Health on protection methods and how to wash and disinfect vegetables using tools provided by both the ministry and UNICEF for this purpose.
Reassurance and a Call to Anticipate
Pharmacists are also ready. The head of the pharmacists, Dr. Joe Saloum, emphasized to "The Call of the Nation" that cholera has two main aspects focused on prevention first, and treatment second. Treatment primarily revolves around preventing dehydration, as this is where the danger begins. He noted that pharmacists are available to provide preventive and treatment guidance to those infected, and directing them to specialized doctors and hospitals in case of deterioration. "Just as pharmacists stood by patients on the front lines throughout the COVID crisis, there are now also 3,400 pharmacies spread across all Lebanese territories ready to provide assistance and suitable medications for treatment." Saloum urged those infected to isolate themselves to protect others, as preventing the spread of infection is one of the essential preventive measures. He also reassured the Lebanese that treatment is available and that the means to prevent the spread of infection are very easy, especially with continuous cooperation with the Ministry of Health. He concluded by stating that the medications used in treatment are not expensive and are provided free of charge in health care centers.
