'We are going to die': Lebanon grapples with cholera outbreak amid unsanitary conditions and failing infrastructure

Hundreds of flies flew around the camp in a frenzy as Hussein Matar, 44, and Mrs Sheikh Mohammad Ahmad Sheikh, 39, walked through its pathways, apologising profusely for the putrid smells and filth that encapsulated the entirety of the camp.

Ahamd Sheikh pointed to a small stream of water behind her tent that was filled with garbage and waste that had become a feast for insects and rodents.

"No one has come here in the two years that we’ve been here... We call and we call but no one responds to us"

Between the two tents, there was more dirty water, caused by the waste coming from Ahmad Sheikh's brother.

According to both Matar and Ahamd Sheikh, they have repeatedly asked for help cleaning up the camp only to be ignored.

"No one has come here in the two years that we’ve been here," she told The New Arab. "We call and we call but no one responds to us."

Matar says that they have had no cases of cholera in their camp located at the epicentre of the infectious outbreak in Bebnine, a district in the northern Akkar region of Lebanon, but he also described many people in the camp, himself included, getting sick as a result of the water that they use. Despite some of the camp's residents getting diarrhoea, they did not seek medical care as they could not afford the costs.

Every day they worry about what will happen to them if their situation does not improve.

"We are going to die," Matar exclaimed to The New Arab.

Managing the outbreak

Lebanon recorded its first cholera case since 1993 on October 6 when a Syrian man living in Camp 045 in Bebnine contracted the bacteria from contaminated water.

Since then, infections have spread to all corners of the country, reaching the capital Beirut and going as far south as the city of Tyre.

"Given the wide range of severity in cholera cases, medical experts say that there could be many more cases that go unreported"

Lebanon has currently recorded 448 confirmed cases of cholera along with at least 18 deaths, but the Ministry of Public Health is also monitoring another 2,274 suspected cases that have yet to be confirmed.

However, given the wide range of severity in cholera cases, medical experts say that there could be many more cases that go unreported.

Dr Ghassan Matar, the laboratory director for the Centre for Infectious Diseases Research, has been working with the Health Ministry and World Health Organization to test cases of cholera in both Lebanon and Syria, which has been grappling with its own outbreak of cholera for several months now and has well over 10,000 cases nationwide, and says that the bacteria was likely able to enter the country through contaminated water, adding that the conditions in the refugee camps made it easier for cholera to spread there.

"It started in rural areas in the north [of Lebanon] and mainly in the Syrian camps," Matar told The New Arab. "The Syrian refugee camps do not have enough water in order to drink and make use of it. So they were actually getting water from any kind of resource. This water is polluted and they acquired the infection, probably, in this way."

The doctor added that they needed to do more research to understand how cholera has spread throughout the country, but that the ongoing economic crisis and failing infrastructure are likely culprits for exacerbating the situation.

"Due to the economic crisis, a lot of maintenance has not been done," he explained. "And when you don’t have the infrastructure that’s not well maintained due to the economy, then you never know how things are going to be and in what state. The pipeline is part of the infrastructure canalization, whether water is mixed with sewage. This needs continuous maintenance. So definitely, the economy and the infrastructure have affected the spread of cholera."

In response to the outbreak, the Health Ministry has worked to inform the public about the bacteria and how it spreads as well as how to avoid contracting it.

"When you don’t have the infrastructure that’s not well maintained due to the economy, then you never know how things are going to be and in what state. The pipeline is part of the infrastructure canalization, whether water is mixed with sewage"

Caretaker Health Minister Firas Abiad also said that anyone who has cholera and goes to a government hospital for treatment will have "100 percent" of their expenses covered.

The arrival of 13,440 doses of the cholera vaccine to Lebanon, facilitated by the French government has given some in the medical community hope that Lebanon might be able to get a better grip on the outbreak.

According to Matar, these first doses will go to healthcare workers who are at risk of contracting the infection, such as frontline workers and those working the laboratories, while the second batch of doses would be for people living in high-risk areas, such as Bebnine. The third batch will be for whoever else would like to receive the vaccine.

While the arrival of the vaccine will likely help makes things easier for hospitals and medical centres throughout Lebanon, until a majority of people receive it, they will continue facing daily uncertainty as to whether or not they will be inundated with patients.

On the frontlines

When cholera first began spreading throughout Akkar, it caught doctors off-guard.

Lebanon had not had a case in nearly 30 years so many did not even know what they were dealing with when patients came through their doors.

"We first heard of cholera through the media," Dr Nahed Saaddine, director of the Iman Medical Centre in Bebnine, told The New Arab. "We did not know what it is. We heard about it when we were younger, but then it disappeared."

According to Saaddine, the bacteria was able to spread because some water in the area had been contaminated but it was relatively contained at the start. However, when there was a rainstorm, it allowed for the contaminated water to bleed into some of the main water sources for the area, leading to the widespread outbreak that the country is experiencing.

In order to help treat cases, the Health Ministry asked the Iman Health Centre to use the empty auditorium below the main floor as a field hospital to take care of patients that come to seek help.

As soon as word spread, though, that there was a treatment centre at Iman, they quickly became inundated with patients since it was closer for many people and, more importantly, it was significantly cheaper than going to a larger private hospital that charge huge fees for treatment.

"So, in four hours, we got 50 patients," Saaddine recalled. "These couple of days were hectic. The work did not stop. The cases that people think the media exaggerates about are actually there; it’s not an exaggeration."

Since there is no specific test that a hospital can do to confirm if someone has cholera, besides sending samples to a laboratory for confirmation, they treated each patient as if they were infected if they showed any symptoms.

The medical centre became so busy at one point that if people were not in critical condition, they would have to turn them away so that they could reserve the 20 available beds for the patients that were "dangerous cases."

In some instances, if there was no room at the centre, they would send doctors and nurses to people's homes in order to check up on and treat entire families that had become infected.

"The medical centre became so busy at one point that if people were not in critical condition, they would have to turn them away so that they could reserve the 20 available beds for the patients that were 'dangerous cases'"

During the time that The New Arab visited the underground treatment centre, there were initially three patients getting IV drips, but four more cases arrived soon after.

One patient, a Syrian woman from a nearby camp, was receiving fluids from an IV along with her daughter who was in the bed next to her. Her husband sat on a chair between the two of them, concerned for their safety.

"I’ve been suffering for six days," the woman told The New Arab. "The IV is just to help with giving me the nutrients that I’ve lost, but I do not feel better."

Saaddine said that the centre is doing the best that it can to help patients, but they are woefully unequipped to handle the outbreak.

Just a few days prior, the centre had so many patients that people were sitting on chairs or simply just lying on the floor so that they could be treated.

"We lack the equipment. This hospital was prepared in four days," she explained. "We are not ready to have all these patients. Thank god people in the area, families and friends, are helping by volunteering and assisting the patients. We do not know what the protocol is, we don’t know how to deal with this disease, we are just doing what is best by cleaning all the time, sterilizing and removing garbage."

While Saaddine says that the situation is improving, she still lives in constant fear that the centre will become overwhelmed.

Because entire families and neighbourhoods have shown up at the centre seeking medical care, Saaddine says that "the water tanks, they are old and polluted, and the water is coming and going is being stored which is causing more cases," something that was confirmed by both Ahmad Sheikh and Matar.

Unanswered calls

Cholera, like many other infectious diseases, spreads through contaminated water.

This is something that has caused Ahmad Sheikh and Matar to worry.

Throughout the camp that they live in, there is water that is mixed with rubbish and human and animal waste. Since it is still water and not flowing, it has allowed insects to reproduce there as well, creating even more unsanitary conditions.

Ahmad Sheikh and Matar moved to this camp two years ago after being forced to move because they faced many problems in the camp that they lived in for several years after fleeing Syria at the start of the civil war.

"People come and see what’s happening here, take photos and then leave. No one ever responds after that"

In the time that they have lived at this new camp, conditions have continued to worsen and no one has answered their calls to help them clean the camp so that diseases would not spread.

"People come and see [what’s happening here], take photos and then leave. No one ever responds [after that]," Matar stated.

Both Matar and Ahamd Sheikh said that they have tried to contact the UN for help, even asking the owner of the land that they live on to reach out, but they say that they never receive any response.

The United Nations High Commissioner for Refugees, when asked for comment on the organisation's response to the cholera outbreak, told The New Arab that they were working with the Health Ministry, other UN agencies and NGOs to help tackle the bacteria.

"UNHCR’s specific interventions aim at enhancing cholera prevention, response and surveillance structures, to contain the outbreak, including supporting the vaccination campaign; increasing the capacity of health care facilities and ensuring access to early diagnosis, treatment and timely life-saving support for patients; strengthening community awareness about cholera; and ensuring timely and appropriate hygiene and shelter measures to control the spread of cholera, with special attention given to the populations in high-risk areas," Lisa Abou Khaled, a spokesperson for the UNHCR, stated.

Abou Khaled added that the UNHCR is covering the hospital costs for all refugees that receive cholera treatment and aiding the process to administer the vaccine to "refugees and Lebanese nationals."

"The UNHCR is converting UNHCR-funded COVID-19 facilities into cholera treatment centres in Halba and Tripoli Governmental hospitals," Abou Khaled said. "UNHCR also dispatched an emergency stock of medicines and supplies to Halba Government Hospital."

All that they have is a card from the UN that allows them to purchase food every month, but, for the family of six, even that is not enough.

"The situation in the last camp that we lived in was better than what is happening here," Matar said. "But, in general, it was more dangerous up there [in the other camp]."

A short walk from the tents that the families live in is a small wooden shack that serves as the sole community toilet which was little more than a hole in the ground. But even that was filled overflowing with human faeces and was covered with countless flies.

"The toilet is so disgusting," Sheikh Ahmad muttered.

"Will it take people getting sick here for them to come"

There are several water tanks throughout the camp that were filled with water, but Matar said that no one dared to use them except for cleaning. If they want water to drink, then they have to go to a nearby store that sells gallons of filtered water.

However, they remain concerned that a child could possibly drink from this contaminated water, risking the possibility of them getting sick. Matar says that they have requested chlorine tablets that they could use to disinfect the water tanks, but they have not received any so far.

"Will it take people getting sick here for them to come," Matar questioned. "Come now and see the situation and see what you can do. If they can keep it clean, then that would be enough. We need to bring chlorine tablets for the water tanks but there aren’t any. Now, if a child drinks that water, they will become sick. We bring water that is only meant to be drunk and the water tanks are only for cleaning things like washing clothes or showering. Nothing else."

Matar and Ahmad Sheikh already have a two-year-old child that needs medicine every day because it did not get enough oxygen when it was born. What little money they have goes towards their basic necessities and their child's medicine, so "if the children get sick, we can’t take them to the doctors."

The camp's residents have become exhausted as they feel like they are going from crisis to crisis.

"Before there was corona and what has come now? Cholera. There is no answer. No one answers. What is going to happen? I don’t know," Matar stated solemnly.

Every night, they go to sleep, coughing and gagging on the smells that come from the waste in the camp and wake up in the morning, worried that this could be the day that they are finally unable to escape infection.

Nicholas Frakes is a freelance journalist that reports from London, the Middle East and North Africa.

Follow him on Twitter: @nicfrakesjourno