Syrians in refugee camps face a cholera nightmare in Lebanon

SAADNAYEL ­­– On a gray and rainy morning, 5-year-old Mahmoud played in one of the many murky puddles dotting a refugee settlement Saadnayel, in Lebanon’s eastern Bekaa Valley on Thursday. A few days earlier, he was hospitalized with acute diarrhea, vomiting and fever.  

Mahmoud was among the 3,116 suspected cholera cases that Lebanon has registered since its first case was documented on October 5, in another Syrian refugee settlement in northern Lebanon. Since then, the Vibrio cholerae bacteria has been detected in all of the country’s eight governorates, and eighteen people have died.

Cholera is a bacterial disease mainly spread by ingesting contaminated food or water, or by direct contact with the feces of an infected person. The main symptom is acute diarrhea, which is easily treatable with an oral rehydration solution, but if left untreated the disease can lead to death by dehydration within hours. A quarter of Lebanon’s cases have been reported in children under four years old, according to UNICEF. Malnourished children are at higher risk because their bodies contain less fluid.

Mahmoud’s family said he got sick when he ate fruit without washing it first. “He ate an apple and two days later got sick,” said his aunt, Farial Ahmad, a Syrian refugee from Homs. Mahmoud was severely dehydrated. “He was hospitalized for four days, they put him on an IV,” she explained.

Initially, the family sought treatment at the Bekaa Hospital, which rejected them. Al-Abdallah Hospital, also in the Bekaa Valley, admitted Mahmoud, but charged them $50 for analysis and 250,000 LBP (approximately $6 approximately at the parallel market exchange rate) for the treatment. “My daughter and my granddaughter were also vomiting and had diarrhea for four days,” Farial added. 

Nadine Mazloum, a UNHCR spokesperson, told Syria Direct that the UN Refugee Agency covers “100 percent of hospital admission costs for refugees who are confirmed or suspected of having cholera.” However,  Mahmoud’s family had to pay for his treatment.

Cholera, which spreads easily in areas with insufficient sanitation and access to safe water, can be prevented with oral vaccines and ensuring access to safe water. Lebanon’s current cholera outbreak is its first since 1993. The current outbreak began in Afghanistan in June and then spread to Pakistan, Iran, Iraq and neighboring Syria. The World Health Organization (WHO) reports an “unprecedented rise” in cholera outbreaks: 29 countries worldwide, and eight countries in the Middle East and North Africa.  

Around 21 percent of the estimated 1.5 million Syrian refugees in Lebanon live in informal settlements. Generally, these camps lack access to clean water and proper sewage disposal. 

Farial’s family of six buys water trucked into the camp because it is their most affordable option. They receive 3 million LBP ($76) a month from UNHCR, but “everything is getting more expensive,” she said. “A gallon of bottled water is 20,000 LBP [$0.50], which we can’t afford. Each month, we buy drinking water from a truck that fills our [five-gallon] tank for 150,000 LBP [$4].” Still, “you can’t be sure about its quality,” Farial’s son Ahmed said. 

“Roughly half of the refugee settlements rely on water trucking, while some are connected to water networks, and others rely on alternative arrangements,” explained Nadine Mazloum, a UNHCR spokesperson. 

In another informal camp next to the one where Mahmoud’s family lives, one alternative arrangement to buying water is a murky spring. Rabia Harfoush, 27-old refugee from Qusayr, explained that the water from the spring, where rainwater also collects, is used to irrigate the potato fields surrounding the camp. But out of necessity, her family and others also use it to bathe and wash dishes. 

Rabia Harfush and her daughter next to a small spring behind their tent in Saadnayel, Lebanon, 10/11/2022 (A. Medina/Syria Direct)

Rabia does not receive UNHCR aid, and works in the potato fields with her husband to cover their 500,000 LBP ($12) rent and 1 million LBP ($24) electric bill. “The Norwegian Refugee Council gave us a bit of water, so now we are not using the spring water, but when we run out of the NRC water, we use the spring. We can’t pay for water [for household purposes],” she said.

Her family spends 100,000 LBP ($2.50) a week on trucked-in drinking water.  In Lebanon, the cost of water provision has increased thirteen-fold since 2019, at a time when three-quarters of the population lives in poverty. 

In 2022 so far, the water sector within the Lebanon Crisis Response Plan, a UN relief plan aimed at refugees and vulnerable Lebanese population, has received $107.3 million out  of the $247 million it has requested from donor countries.UNICEF has also launched an appeal for an additional $38 million in aid to deal with Lebanon’s cholera outbreak, and is distributing 32,000 oral rehydration salts to symptomatic or high-risk individuals, 400,000 chlorine tablets to sterilize water tanks, and 1,026 disinfection kits in refugee settlements where cholera is spreading.

Huda Khalad chats with Fauza al-Alawi and another friend in their informal camp in Saadnayel, Lebanon, 10/11/2022 (A. Medina/Syria Direct)

Huda Khalad, originally from the Aleppo countryside, sat talking with her neighbor Fauza al-Alawi, originally from Idlib, in their camp in Saadnayel on Thursday. They both receive food assistance and hygiene kits from UNHCR, but they say it is not enough.  Huda spends 200,000 LBP ($5) a month to fill her five-gallon tank with potable water. 

“Every week we get a water tank (for domestic purposes) from UNHCR. They [had] reduced the water they were giving us, but after the cholera came, they gave us more,” Huda said. In refugee settlements, the minimum daily amount of water per person  for drinking, cooking, hygiene and domestic needs should be 35 liters, but due to funding restrictions, some settlements only received 7.5 liters per person, according to a UN study. 

Sanitation is also a persistent concern in the informal settlements. “When it rains, [the water] mixes with sewage. It gets dirty, it smells bad and people get allergies,” Fauza said. A few meters from where she sat,  used water mixed with garbage in an open ditch.

Fauza and Huda say they have not heard of cholera cases in their camp, but Fauza’s son was recently hospitalized with jaundice—an illness that can be caused by low caloric intake or dehydration.

Garbage and sewage water mix next to a tent in a refugee camp in Saadnayel, Lebanon, 10/11/2022 (A. Medina/Syria Direct)

Behind them, a queue of women waited in front of the van from the NGO Endless Medical Advantage (EMA) to get medical treatment.  “We cover 40 camps and treat around 150 people per day, for free,” said Muhannad Ghadban, from EMA. “Now we have many diarrhea cases but we can’t be sure if they are cholera, so we do a follow up and if it’s cholera we treat them and if they need hospitalization we send them to the hospital,” he added. 

A 20-minute drive from the settlement in Saadnayel, the cholera section at the MSF (Doctors Without Borders) hospital in Bar Elias was empty on Thursday. 

The center, which offers free treatment to any patient regardless of nationality, opened its doors to cholera patients on October 31. “We started with 10 beds, and we have the ability to increase to 20 or more in the coming period, Doctor Wael Harb of MSF said. “So far, we’ve had 14 suspected cholera cases, two of whom were admitted, the rest were sent home with oral rehydration treatment.”

The most vulnerable groups are “pediatric cases, elderly patients and patients with comorbidity like diabetes, hypertension or cardiac insufficiency,” Harb explained. When treating cholera, a fast response is key “because the patient loses a lot of fluids and electrolytes” which can “lead to severe dehydration and maybe death.” 

Harb recommended seeking medical care after three instances of watery diarrhea. The cholera bacteria “stays in the stool of the patients from seven to 14 days, so after discharge, they have to take the medication to prevent transmission,” he added.

The WHO has provided laboratory reagents, treatment kits and rapid diagnostic tests to Lebanon’s 12 hospitals designated for cholera treatment, as well as three prison facilities. But “healthcare worker migration, disrupted supply chains and unaffordable power solutions have severely weakened the response capacity of hospitals and primary health care facilities which are now threatened by the growing outbreak and increasing caseloads,” the UN agency told Syria Direct in a written statement.

This week, Lebanon received 600,000 cholera vaccines from the WHO. A three-week vaccination campaign is set to start on Saturday, November 12 and will target refugees and residents of surrounding Lebanese communities ages one year and older in the most affected areas. 

 A dilapidated water system

Lebanon’s cholera outbreak is not only a major threat in refugee camps, but nationwide, as the country’s already fragile water infrastructure has been further eroded by the economic crisis. 

Electricity shortages and high fuel prices mean government-run water stations are unable to pump enough water through the network, pushing people to buy private water from trucks, which is more expensive and has less quality control.  The same factors have also affected wastewater treatment plants and sewage disposal. 

“In Lebanon you already have a weak water infrastructure, but then you add the electricity cuts and the lack of proper sewage disposal and treatment, it just makes the situation more complicated,” Basma Tabaja, the Deputy Head of the Lebanese delegation of the International Committee of the Red Cross (ICRC), told Syria Direct. 

To avoid the further collapse of Lebanon’s water infrastructure, international organizations like ICRC and UNICEF are providing fuel to water pumping stations and wastewater treatment plants, distributing water tests to Lebanese authorities and rehabilitating water infrastructure.

But in refugee camps facing the same economic crisis with even less working infrastructure, residents’ options are limited.