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Amid vaccine shortages, Lebanon faces its first cholera outbreak in three decades

Darine Al-Ahmar (left), who directs a primary care health center in Douris, Lebanon, and Josette Hajjar, with the Lebanese branch of the Mérieux Foundation, have seen the number of cholera cases rise around their region.
Ari Daniel/NPR
Darine Al-Ahmar (left), who directs a primary care health center in Douris, Lebanon, and Josette Hajjar, with the Lebanese branch of the Mérieux Foundation, have seen the number of cholera cases rise around their region.

DOURIS, Lebanon — In the village of Douris in the Bekaa valley, a fertile farming region in the east of Lebanon, Darine Al-Ahmar stands guard at the primary health center she directs. She wears a purple top under a purple sweater. And through her glasses (that sparkle with purple glitter), Al-Ahmar looks toward the direction of a distant town where a cholera outbreak is brewing, moving toward her health center.

"The big problem," she says, is "if the groundwater become populate." She means contaminated with Vibrio cholerae, the bacteria that causes cholera, a diarrheal disease that, if left untreated, can rapidly dehydrate someone, cause kidney failure and lead to death.

Fortunately, there is an oral vaccine that's quite effective. But there's not enough of it to meet the surge in cases around the world. A total of 29 countries across the Caribbean, Middle East, Africa and South Asia are reporting cholera, a situation fueled in large part by poverty, conflict and climate change.

Lebanon is experiencing its first outbreak in nearly three decades. The first case was discovered a month ago, but now it's spread across the entire country. There are already at least 2,700 cases and 18 deaths.

Such numbers prompted the International Coordinating Group on Vaccine Provision, which manages emergency vaccine supplies, to reduce the recommended two-dose vaccine regimen to a single dose last month. The goal was to stretch the supply and give more people at least some measure of protection.

"This is really an emergency measure — and it's a temporary measure," says Tarik Jašarević, a spokesperson with the World Health Organization. "We hope that the cholera outbreaks will be brought down not only by the vaccines, but also by other measures that we have at our disposal."

Cholera spreads in water where there's poor sanitation. For many people, those "other measures" involve the basics of securing clean water.

The Ministry of Public Health in Lebanon says it's boosted water surveillance and testing, set up a field hospital and treatment center, and coordinated with the Ministry of Energy to try to get electricity to water treatment stations. And with the help of the WHO, Lebanon has just received 600,000 doses of the cholera vaccine. The first wave of an ambitious immunization program starts up Nov. 12, with a focus on vulnerable populations in high-risk areas.

In the Bekaa Valley, the groundwater Al-Ahmar is referring to fills up the wells that the villages in this area depend on. The people here use that water to shower, irrigate their farms, brush their teeth and wash their vegetables.

The problem is that the wastewater isn't being treated before it returns to the lakes and rivers. This is the water flowing out of the toilets and sinks from homes in the region and from the numerous informal settlements here. (The Bekaa is where many of the million-plus Syrian refugees in Lebanon have settled.)

"Our water [has] become dirty," explains Al-Ahmar, who works for the Amel Association NGO. And because the water in the Bekaa Valley is all connected, she says the whole area is in danger.

In the last few years, Lebanon has been hit with crisis upon crisis: a financial collapse that's devalued the currency, political instability, COVID, and widespread power shortages. This means that in addition to decaying infrastructure, there's insufficient energy to fuel the water filtration plants, which has allowed the bacteria to spread. The WHO is concerned that the country's cholera outbreak could swamp an already precarious health system.

Al-Ahmar makes a daily announcement in the health center about how to avoid cholera, such as washing hands thoroughly and adding chlorine tablets to water.
/ Ari Daniel/NPR
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Ari Daniel/NPR
Al-Ahmar makes a daily announcement in the health center about how to avoid cholera, such as washing hands thoroughly and adding chlorine tablets to water.

"I'm very, very upset," says Al-Ahmar. "Why Lebanon comes to these days? Why Lebanon don't have electricity? Why Lebanon don't have water?" Cholera presents itself when there are problems in our society, she acknowledges.

Inside the health center, it's tidy and bright. Thirty people are waiting, including a bunch of kids and families. There's a fair bit of coughing. It's cold season, after all. One of the women in the waiting area is 34-year-old Mona Ghorly. She lives nearby and says she's not afraid "because I didn't see anyone have cholera."

But Chahina Ghorly, her 48-year-old aunt, feels it's only a matter of time. For her, it's like a coming storm. "People, they see the water is polluted," she says through a translator. "They see the sewage passing by. So yes, we are afraid that cholera will be more in this area."

It's a well-founded concern. "The numbers are getting higher, so this is not something that we can deny," says Josette Najjar with the Lebanese branch of the Mérieux Foundation, a global health NGO headquartered in France that helps support this health center.

"Today, mainly in the rural areas," says Najjar, "I'm not sure that we have the mean[s] to resolve these structural problem[s] linked to the water, to the wash."

This is why this health center is taking an approach focused on education. Since early October, Al-Ahmar has been making a daily cholera announcement to the patients in the waiting area. Today, she's speaking to half a dozen women in hijabs and a few small children.

"Like corona, we have now cholera," she often says. "So you should be aware." She enumerates how to avoid cholera, including washing your hands thoroughly and adding chlorine tablets to your water to kill the cholera bacteria.

"And any one of you feeling the symptoms, don't wait to go to the doctor," she adds. The pharmacy here will soon stock the oral rehydration solution that can save someone from rapid dehydration. But Al-Ahmar also explains how to make it at home with clean water, sugar, and salt.

These are life-saving measures intended to slow down the outbreak. Soon, the one-dose vaccine is scheduled to arrive at health centers like this one and hospitals across Lebanon.

Al-Ahmar's small audience listens closely. Don't worry, she tells them. The clinic will care for them if they get sick. She smiles.

Dr. Hassan Kak is disappointed in how the outbreak is being handled. "In 2022, person should live good life. It's water. It's amazing thing. It's a source of life," he says.
/ Ari Daniel/NPR
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Ari Daniel/NPR
Dr. Hassan Kak is disappointed in how the outbreak is being handled. "In 2022, person should live good life. It's water. It's amazing thing. It's a source of life," he says.

Al-Ahmar says she isn't too worried. She feels like COVID was worse, and there haven't been any cholera cases at the clinic yet. With these preventative measures, she thinks her community will be OK.

But Dr. Hassan Kak, a physician and pediatrician here, is concerned. He's also angry at what he views as a kind of national neglect.

"It's sad to say that our government is dealing with us not as humans," he says. "In 2022, person should live good life. It's water. It's amazing thing. It's a source of life."

And here in Lebanon, as in Haiti and Pakistan and Malawi and so many other countries right now, water can also be a source of serious illness. And even death.

Copyright 2022 NPR. To see more, visit https://www.npr.org.

Ari Daniel is a reporter for NPR's Science desk where he covers global health and development.