Cholera is Coming

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Cholera Is Coming

Laurie Garrett

The last great epidemic of Vibrio cholerae to hit Africa and the Middle East occurred from 1997 to 1998. Over 200,000 people were afflicted and some 8,000 killed as the disease spread from southern Mozambique all the way up to the Horn of Africa and into the Middle East. Now cholera is back. And this time it could be much worse.

As in 1997, this outbreak, which is unfolding in the Middle East and East Africa, is growing during an El Niño climate event that is shifting the planets normal rain and drought patterns, spreading the waterborne cholera bacteria. But this outbreak has dangerous added dimensions: Its spread is fueled by war throughout the Middle East, the existence of vast ungoverned and poorly governed tracts of the region, and an enormous refugee crisis.

Although the scope of the current outbreak is moderate so far, with fewer than 11,000 illnesses confirmed, it has already spread across an expanse far larger than the 1997 epidemic, taken a greater toll in the Middle East, and still threatens to travel with refugee populations to a even wider geographic area. Moreover, there is ample reason to believe the official tally is grossly undercounted.

At least 2,000 people in Iraq have contracted cholera since mid-September, and Vibrio bacteria have contaminated the Euphrates River, possibly the Tigris, as well. The epidemic is thriving amid a perfect storm of failed-state capacity in Baghdad, even worse “state” failures in Anbar province and other regions controlled by the self-declared Islamic State, encampments of millions of Syrian refugees and other homeless displaced people, and harsh downpours slamming parts of Africa and the Middle East thanks to one of the worst Pacific El Niño climate events in recorded history.

On Oct. 26, the Syrian American Medical Society, a nongovernmental organization providing aid inside the war-torn country, said it was “very likely” a child living outside of Aleppo died from cholera, possibly due to a widespread contagion in the area. Since January, UNICEF has reported more than 105,000 cases of acute diarrheal disease in Syrian children inside the country, though no laboratories there are available to determine the infectious cause of most of the illnesses. Some, perhaps many, could be due to cholera.

And there is reason to fear the epidemic could spread further afield, too. Turkish officials have assured their people that no cases of cholera have been confirmed among Syrian refugees living in that country. In Lebanon, where millions of refugees reside and government chaos is responsible for a nearly four-month cessation of garbage collection, doctors warn that conditions are ripe for an explosive spread of the disease. On Oct. 2, Greek health officials placed a Dutch tourist in treatment in Athens after the individual developed acute diarrhea on the island of Kos, a landing point for thousands of Syrian refugees. Although cholera was feared, it was never confirmed. Nevertheless, there is growing concern in Europe that with the refugees will come the Vibrio cholerae.

But this cholera crisis already goes far beyond the borders of Iraq or even the lengths of the Euphrates and Tigris Rivers.

It is a pan-African, pan-Middle Eastern epidemic.

As of Oct. 22, the African and Middle Eastern toll for this epidemic had officially reached 10,700 cases, with 170 deaths in Tanzania, the Democratic Republic of the Congo, Uganda, Iraq, Bahrain, Kenya, South Sudan, Kuwait, Iran, the Kurdish territories, and Islamic State-controlled areas, though the numbers are surely not telling the whole story given wartime conditions and the deterioration of the regions medical services. Tanzania, alone, reported 5,000 cases since August, with 74 deaths. Doctors Without Borders carried out a mass vaccination campaign in July, giving 130,000 refugees encamped inside Tanzania the two doses of oral immunization required for protection. And Congo has reported 4,000 cases, including 95 deaths. (Congo has had many rounds of cholera since 1994, when more than a million refugees escaped the Rwandan genocide, perching atop a volcanic area outside Goma, with complete lack of toilet and freshwater facilities.) In the Ugandan southwestern district of Hoima, where some 20,000 refugees from Congo, Rwanda, Burundi, South Sudan, Somalia, and Kenya live in crude camp conditions, cholera broke out in late October following unusually heavy rainfall. As of Oct. 23, 130 people have been hospitalized, and six have died.

Cholera bacteria can travel from one place to another via two ways: through water systems or through infected people. When contaminated human waste is dumped into a river, cholera is carried downstream. Food that is irrigated with contaminated water, and then shipped to another region or country, may carry the disease to new areas if the produce is eaten raw and unwashed. In 1979, I was in a cholera epidemic in Tanzania that spread far and wide on cashew nuts that were packaged by the unwashed hands of people who were infected. International travelers may unknowingly carry cholera and pass it with their waste, spreading Vibrio bacteria from one country to another.

“Man-made and natural disasters can intensify the risk of epidemics considerably, as can conditions in crowded refugee camps. Explosive outbreaks with high case-fatality rates are often the result,” according to the World Health Organization. “In addition to human suffering caused by cholera, cholera outbreaks cause panic, disrupt the social and economic structure and can impede development in the affected communities.”

Climate and weather play a key role. In the 1997-1998 epidemic, the diseases spread was hastened by torrential downpours and mudslides from a periodic climate swing that occurs when transpacific winds change, for reasons unknown, pushing ocean currents out of their normal patterns. This weather pattern is called El Niño. The system occurs when a bulge appears in the Equatorial Pacific and when trade winds cease, allowing waters to stagnate and heat up, spawning dramatic weather events. The wrath of El Niño typically features droughts from the Horn of Africa to India and Australia; torrential storms in eastern Africa and along the length of the Pacific coastline of the Americas; and blasts of cold and blizzards in the British Isles and northern Europe. Climate experts say the 1997 El Niño ranked the strongest on record, creating one of the wettest and hottest years for North America since 1895.

But the El Niño that has been building for the last two years in the Pacific is set to be even larger than the one in 1997-1998, propelled by climate change, which is raising the temperatures of the worlds oceans. Combined with climate change-induced sea warming, the current El Niño is averaging 2 to 3 degrees Celsius above normal for this time of year in much of the Pacific Ocean. Scientists define El Niño as a weather pattern that occurs when a large body of Pacific water is more than half a degree Celsius above seasonally normal temperatures. In August, NASA released satellite imagery comparing the status of El Niño in the summer of 1997 to the one present three months ago: Even an amateur can see that the bulging warm stretch spanning the entire Pacific Equator is far larger in 2015. Officials then warned that massive weather events would begin to occur worldwide.

By mid-October, the El Niño drama was clearly unfolding. The weather system was blamed for holding toxic air in a stagnant dome over Singapore, sending killer typhoons across the Philippines and Southeast Asia, causing a drought in usually drenched parts of West Africa, and showering parts of East Africa with sporadic rains of such force that mudslides and floods resulted. Changes in the hunting patterns of King Penguins have been blamed on El Niño, along with an overall East African drought so dire that the United Nations warns that severe food insecurity may loom. And on Oct. 25, an atmospheric scientist from Colorado State University credited El Niño with feeding Hurricane Patricia, which had record-breaking winds as high as 200 miles per hour.

The impact of El Niño impact on the Middle East, coupled with climate change, has been two-fold: First, temperatures from southern Iraq all the way into Turkey reached record highs this summer, topping more than 122 degrees Fahrenheit. The entire region is now locked in a severe drought, worse than the one some have credited with spawning the Syrian uprisings of 2011 that led to the Assad regimes crackdown and current civil war.

Steps taken by the government of Turkey and the pseudo-government of the Islamic State, both of which have countered unusual heat and drought conditions by damming the 1,700-mile Euphrates River, have compounded the impact of El Niño in the region. In May, Islamic State leaders released a video attacking Turkeys upstream damming of the Euphrates and announcing the groups intention to hoard the remaining water behind a Ramadi dam inside their seized territory. Water levels are now half their usual seasonal level in Iraq and Syria. Similar damming and low water conditions are found, for the same reasons, along the 1,150-mile Tigris River, which also stretches from Turkey to the Persian Gulf.

While torrential rains may foster cholera outbreaks, the Vibrio bacteria become more concentrated when they thrive in still water polluted with human and animal waste, such as now exists in the barely flowing, dammed Euphrates. With less water, there is less dilution. This means the odds that any given glass of Euphrates water or cucumber irrigated with it contains a dangerous dose of Vibrio rises as the water level falls. As long ago as December 2014, there were reports of cholera cases inside the Islamic State-controlled city of Mosul and Anbar province. Unconfirmed reports from Mosul in January put the daily count of new hospital cholera admissions at 15. (The Islamic State would not comment on the outbreak.) In mid-September, the first cholera cases inside Iraq were confirmed, with some in the town of Abu Ghraib, just 15 miles from Baghdad. Within days, the disease had spread into the capital of Baghdad and is now reported in Basra in Iraqs far south, in Kurdish controlled cities like Erbil and Duhok in the north, in refugee encampments nearby, and in multiple other parts of Iraq.

WHO was officially notified by the Baghdad government of the outbreak on Sept. 12 and has deployed an advisory team to the Iraqi Ministry of Health.

WHO was officially notified by the Baghdad government of the outbreak on Sept. 12 and has deployed an advisory team to the Iraqi Ministry of Health. Hygiene teams were quickly mobilized to discourage drinking water from the Euphrates and encourage soap and clean water handwashing. Sadly, Iraqis are now familiar with cholera precautions, as this marks the third outbreak of the disease since the U.S. invasion in 2003. Combined, the previous two caused 4,500 cases and at least 30 deaths. This latest outbreak is of special concern because the Iraqi government is severely weakened in its capacity to govern and maintain basic infrastructures, thanks to its war with the Islamic State. And because El Niño has spawned events across eastern Africa that are contributing to the continental spread of cholera.

More than 10 million Iraqis, Syrians, and Kurds are now living in squalor, displaced within their own countries or in refugee settlements in the region. Among refugees over the last four years have been outbreaks of measles (1,000 cases currently inside Iraq), typhoid fever, hepatitis A, Crimean-Congo hemorrhagic fever, and even polio, which was once all but eradicated from the Middle East. Conditions are ripe for a cholera epidemic that might take hold for a very long time. A WHO spokesperson responded to questions through email about the current conditions of refugees, saying, “The deteriorating security situation in Iraq coupled with the disruption of public health services and increased population displacement makes the conditions favourable for transmitting the disease.” Moreover, the WHO has recently confirmed at least eight cases of the disease among Iraqis living in camps inside the country.

Amid this potentially dire crisis, there is some good news. Across the affected African and Middle Eastern countries, the form of cholera is the same: the Inaba strain. According to the WHO, a paucity of laboratory capacity in the affected countries has made it impossible to do detailed genetic analysis that could confirm that each outbreak involves an identical genotype, but it is assumed that from Congo to Kuwait, this is a shared epidemic. So far the 1,942 samples the WHO has analyzed show no sign of antibiotic resistance, so patients can be treated effectively if they swiftly reach hospital facilities. The cause of death from cholera is dehydration: The bacteria cause profound diarrhea and fluid loss. If treated early, inexpensive antibiotics and rehydration with safe water can cure patients within less than a week.

Having the entire region affected by Inaba is also good news for vaccine use. WHO has 1 million doses of oral anti-Inaba vaccine. WHO will later this week mount a mass vaccination campaign in Iraq, the spokesperson emailed, “using 510,000 doses from a [1] million global stockpile,” to reach a quarter-million displaced and refugee Iraqis. The U.S. government has committed $37 million to hygiene campaigns across Iraq to stop the spread of cholera.

In 1854, cholera struck London, and physician John Snow famously traced its spread to a water pump located on Broad Street. He persuaded local authorities to disable the pump handle and stopped the epidemic. The Broad Street pump story is taught today as a basic tenet of public health, proof that the best way to stop an epidemic is to prevent spread of the germ that causes the disease. In the Middle East, the Broad Street pump is the Euphrates, and possibly the Tigris, and the equivalent of breaking the pump handle is opening all of the upstream dams, allowing a flow to cleanse Vibrio cholerae out into the Persian Gulf.