Cholera Is Coming

An outbreak of the deadly disease is sweeping

across Iraq. But El Nio, climate change, and
Middle Eastern instability could make the crisis
much bigger.

BY LAURIE GARRETT-NOVEMBER 2, 2015

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, todays outbreak, which is unfolding in the Middle East and East Africa, is
growing during an El Nio climate event that is shifting the planets normal rain and
drought patterns, spreading the waterborne cholera bacteria. But this years 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 selfdeclared 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 theworst Pacific El Nio 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 theres 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 nearlyfour-month cessation of
garbage collection, doctors warn that conditions are ripe for an explosive spread of the
disease. On Oct. 2, Greek health officialsplaced 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 theVibrio cholerae.
But this years 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 manyrounds 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 Ugandas
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 Nio. 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. El
Nios wrath 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 Nio ranked the strongest on record, creating one of
the wettest and hottest years for North America since 1895.
But the El Nio 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 Nio is averaging 2 to 3 degrees Celsius above normal for this
time of year in much of the Pacific Ocean. Scientists define El Nio 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
imagerycomparing the status of El Nio 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 warnedthat massive
weather events would begin to occur worldwide.

By mid-October, the El Nio 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 Nio, 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
Nio with feeding Hurricane Patricia, which had record-breaking winds as high as 200
miles per hour.
El Nios 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 Nio 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. Hygiene teamswere
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 Nio 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 todays 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
choleraeout into the Persian Gulf.
SABAH ARAR/AFP/Getty Images

Posted by Thavam