The Next Cholera Epidemic

A cholera outbreak that began in Iraq in mid-September has spread into war-torn Syria. From there, a massive flow of desperate refugees could carry the disease deep into the Middle East and even into southern Europe.

Humanitarian aid physicians working in Syria report that three cases have been confirmed in two cities controlled by the self-proclaimed Islamic State (also known as ISIS): Deir ez-Zor, in eastern Syria; and Aleppo, in the northwestern part of the country. Undoubtedly, these cases are just the tip of the iceberg. Under the best conditions, clinicians usually diagnose only 30 percent of the cholera cases that occur during epidemics; in Syria, where hospitals and clinics have been destroyed by air strikes, they’re likely diagnosing far fewer.

This outbreak was predictable. Cholera is caused by a bacterial pathogen that passes between people via human waste and is easily spread through contaminated food and water. If introduced into crowded refugee camps with rudimentary sanitation, the pathogen can rapidly explode. Millions of people are internally displaced in Syria, and supplies to disinfect drinking water have been cut off outside government-controlled areas. Eight months ago, the World Health Organization (WHO) noted the country’s vulnerability to cholera. And then two months ago, the pathogen struck in neighboring Iraq, where 15 of 18 provinces are now infected. With a porous border and a mass exodus of Syrians, Iraqis, and others under way, cholera’s arrival in Syria was just a matter of time.

Predictable and preventable cholera epidemics have reached historic proportions in recent years. In October 2010, ten months after a magnitude seven earthquake shattered the country, cholera arrived in Haiti, most likely for the first time in over 100 years. The U.S. Army Corps of Engineers had predicted as far back as 1999 that the country was ripe for an outbreak of waterborne diseases such as cholera, a warning echoed by aid nongovernmental organizations after the earthquake. The UN nevertheless ferried soldiers directly from cholera-struck Kathmandu, Nepal, into the country that October without testing them for cholera infection. Cholera erupted in Haiti days later; within a year, more than 450,000 Haitians had fallen ill. A recently launched campaign to rid the island of cholera will take ten years and cost over $2.2 billion.

The disease has now found a home in the Middle East, where crowded refugee camps and make-shift settlements in water-deprived towns and cities provide a perfect breeding ground. In Syria, over 13.5 million people are in need of humanitarian assistance, including clean water and safe shelter, which can protect them from scourges such as cholera. Nearly 2 million have sought refuge in Turkey, where the vast majority must make do with tents or squat in abandoned buildings and semi-demolished houses, with no reliable access to safe water or sanitation. In Lebanon, where there are no official camps for refugees, over a million Syrians reside in informal settlements and shantytowns. Already diminishing water supplies—Lebanon is in the midst of a years-long drought—are being stretched beyond the limit. At one settlement in Beirut, a refugee described the dwindling, contaminated supply as “hell water.” Under such conditions, cholera thrives.

As cholera wends its way through the battered alleys and tattered refugee tents of northern Syria, a similarly unprecedented epidemic is poised to unfold in the Middle East. The difference is that averting it is still possible. But the time to act is now.

Like cholera in Haiti, the unprecedented Ebola virus epidemic in West Africa was similarly predictable and preventable. Scientists had uncovered evidence of the Ebola virus circulating among people in Liberia as early as 1982, but no one followed up on the finding. The WHO was slow to respond even after the virus started killing people in late 2013. It didn’t sound the alarm until nine months later; by then, the virus had already started to expand exponentially and had spread into three capital cities with a combined population of nearly three million. In the end, the Ebola virus killed more people in West Africa than it had in all previous outbreaks combined.

Cholera may not reach epidemic proportions in the Middle East since the cholera bacterium thrives in warm surface waters; so it is possible that colder winter temperatures will send it into dormancy. Or that it will be carried into places where people enjoy sufficient access to clean drinking water and sanitation so that it can’t take hold.

But it may very well erupt. And once it does, the caseload will grow exponentially, making containment difficult, expensive, and uncertain. That is why the most efficient and cost-effective way to control pathogens such as cholera is by stamping them out before many people are infected. But the WHO, the premier global health institution tasked with coordinating such efforts, is ill-fitted for the task.

Despite warnings that Syria was vulnerable to an epidemic of cholera, few precautions were taken. The WHO was not able to coordinate a mass vaccination campaign against cholera in Iraq until six weeks after the outbreak there started, leaving neighboring Syria dangerously vulnerable. By the time the campaign started, the disease had already spilled out of the country into one of the most broken parts of the world. Nor did the agency take measures to ensure that cholera could be spotted if it did appear in Syria. The laboratories capable of diagnosing cholera in northern and eastern Syria have been destroyed by the Bashar al-Assad regime. But the agency failed to position diagnostic lab equipment that can quickly distinguish cholera from other diseases, such as PCR machines, in accessible cross-border areas. As a result, cholera cases are being detected through cruder tests, which in a cruel Catch-22 the WHO does not accept as proof. As a result, despite a steady stream of reports of cholera-like disease from humanitarian aid doctors, for now, according to the agency, Syria is officially “free from cholera.”

The trouble with the WHO is that it is politically constrained; it must obtain governments’ permission to work in their territory. In the case of Syria, that means the WHO must coordinate its activities through the Assad regime (the same regime that has destroyed nearly 60 percent of the country’s public hospitals through air strikes). This limits the WHO’s activities to government-controlled territories.

The WHO is also financially dependent on donors. A May 2014 report from Chatham House, a British think tank, points out that more than 75 percent of the WHO’s budget is controlled by outside donors who dictate how that money is spent. An analysis of this donor-driven portion of the WHO’s 2004–05 budget revealed that less than ten percent of these funds were earmarked for noncommunicable diseases (heart disease and diabetes, for instance) that account for more than half of all deaths worldwide, over three-quarters of which occur in poor or middle-income countries.         

These constraints slow down and politicize the WHO’s work. Its languorous pace may not hamper its efforts to curb diffuse, non-infectious conditions such as obesity and cancer, but it is a profound misfit for stealthy, fast-moving contagions. And thanks to intensifying environmental disruption, political conflict, and accelerated global mobility, we face more of these today than ever before. Between 1940 and 2004, over 300 pathogens have either been newly introduced into human populations or have emerged in places where they’ve never been seen before. The Ebola virus and cholera—along with avian influenza, Middle East respiratory syndrome, severe acute respiratory syndrome, and novel forms of antibiotic-resistant bacteria—are among them.                      

Recent failures to contain the Ebola virus and cholera continue to exact heavy tolls; both Haiti and Guinea in West Africa are still struggling to control these newly arrived pathogens. As cholera wends its way through the battered alleys and tattered refugee tents of northern Syria, a similarly unprecedented epidemic is poised to unfold in the Middle East. The difference is that averting it is still possible. But the time to act is now.