Cholera Epidemic Could Be Biggest Danger to Middle East

The fighting in Iraq and Syria is severely affecting sanitation conditions and raises the risk of an epidemic.

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A child cries as a large group of migrants and refugees wait to board a train after crossing the Greek-Macedonian border, December 1, 2015.
A child cries as migrants and refugees wait to board a train after crossing the Greek-Macedonian border, December 1, 2015.Credit: AFP
Dan Barel
Dan Barel

The fighting in Iraq and Syria is creating one of the most severe humanitarian crises the Middle East has ever known. And the military, political and social upheaval those countries have experienced in recent years is also beginning to take its toll on public health.

As has been the case throughout history, the fighting in the region is exposing the population there to epidemics due to poor sanitation conditions that promote the spread of disease. These conditions include damaged water and sewer infrastructure; the inability to dispose of sewage and lack of access to clean drinking water; medical care that is of poor quality or completely absent; a lack of funding for health care; and the dense living conditions in which refugees and other displaced populations find themselves.

It was reported recently that cholera – which was initially diagnosed in a refugee camp not far from the Iraqi capital, Baghdad – has afflicted more than 2,500 Iraqis and also spread to Syria. This has been seen particularly in areas under the control of Islamic State, where it has infected an unknown number of people. Now, the constant flow of Syrian refugees might result in an epidemic deep inside the Middle East: it has already surfaced in Kuwait and Bahrain.

The cholera bacterium is spread in poor sanitary conditions, including standing sewage and the total absence of clean drinking water, along with poor medical care and lack of funds for said care. It is an intestinal bacterium that is spread in sewage from the waste of those infected and where sewage is not treated. It can then make its way into food and drinking water when crops are irrigated with the wastewater, causing severe intestinal infection. Cholera causes diarrhea and vomiting, which quickly results in a loss of fluids, resulting in death within less than a day of the appearance of initial symptoms if it remains untreated.

An incidence of cholera is the clearest possible indication of the level of sanitation in a given area. The more that drinking water is polluted, sewage not efficiently disposed of and medical services are poor, the greater the risk of an epidemic. The World Health Organization is currently attempting to curb the spread of cholera in Iraq by providing the population with clean water and vaccinations. But these have not been totally successful, due to the massive humanitarian crisis there. And in Syria, which is under the control of a number of different factions, it is not even possible to try to address the situation.

Iraq’s major source of freshwater is the Euphrates River, which connects Iraq with Syria and Turkey. The river acts as a drain for sewage effluent in addition to providing drinking water. It is thought that cholera bacteria contamination of the river was initially discovered in Syria about a year ago, but was not dealt with due to the war there. Water purification facilities along the river have not been functioning and, therefore, the polluted river water has been slowly flowing through its entire length in Iraq.

Syrian migrants protesting against restrictions limiting passage at the Greek-Macedonian border, December 1, 2015.Credit: AFP

In Turkey, where the river has its source in the Mount Ararat region, a dam has recently been built that has greatly reduced its flow. As a result, the less the water is diluted and the more the river flow is reduced, the greater the risk that the Euphrates will spread disease and intestinal infection.

In peacetime, rivers serve to connect economies and cultures. However, in these times of war and conflict, the river is creating a deepening health-care crisis. As the shortage of water for drinking and agriculture increases, the day in which the river becomes a focal point of conflict between countries is drawing closer.

Throughout history, wars have caused health crises that have ultimately claimed more lives than the battlefields. About 100 year ago, during World War I, the Ottoman armies expelled hundreds of thousands of Armenians toward Syria and Mesopotamia (the area between the Tigris and Euphrates rivers, most of which is today Iraq, with a part in Syria) under exceptionally difficult conditions. Most of the refugees died in typhus and cholera epidemics, which spread throughout the Middle East.

It appears the region has now turned back the clock 100 years, to one of the darkest periods it has known – from a medical standpoint, too. Disease-bearing outbreaks know no regional boundaries and, consequently, the Middle East has retreated to a new age of epidemics.

Dr. Dan Barel is a microbiologist and medical historian, and the author of “An Ill Wind: Cholera Epidemics and Medical Development in Palestine in the Late Ottoman Period” (in Hebrew).

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