Cholera in Syria: Is Europe at risk?

Cholera. The word still conjures images of pestilence; emaciated bodies, sunken eyed and ashen-faced, clinging desperately to life as what little remains of their dignity ebbs away in a putrid mix of vomit and watery excrement. Rudyard Kipling, writing in 1890, chronicled the spread of cholera epidemics in India through large movements of people and pilgrims travelling across newly developed rail and road networks:

Many died at the feet of their god; the others broke and ran over the face of the land carrying the pestilence with them. It smote a walled city and killed two hundred a day. The people crowded the trains, hanging on to the footboards and squatting on the roofs of the carriages, and the cholera followed them, for at each station they dragged out the dead and the dying. They died by the roadside, and the horses of the Englishmen shied at the corpses in the grass.

Worldwide, cholera is still a significant concern with numerous outbreaks in recent decades, and an estimated 1.4 to 4.3 million cases occurring yearly which result in approximately 142,000 deaths. The truth about cholera in advanced economies of the modern world though is different. In today’s Europe cholera no longer holds the apocalyptic threat it once did.

Cholera is a disease caused by a bug amongst many bugs that we now know a great deal more about than when Kipling penned his prose. It is an acute gastrointestinal infection caused by ingestion of the bacterium Vibrio cholera, present in faeces, contaminated water or food. Humans are the only known host. Symptoms occur in about 25 per cent of people that get infected and variably include; fever, vomiting, muscle cramps and a watery diarrhoea that can lead to dehydration.

The public health risk to the community arises because cholera is highly infectious. The bacteria also stay in the faeces of infected individuals for up to 14 days and are shed back into the environment, possibly infecting others. Once infection occurs, early diagnosis and access to appropriate treatment is imperative.

Timely treatment results in a complete recovery in the majority with a mortality rate of less than 1 per cent. Yet left untreated, the mortality rate can climb to as much as 50 per cent for severe infections, with even healthy adults succumbing to the disease in a matter of hours following the onset of symptoms.

The disease is primarily linked to poor access to safe water and adequate sanitation and so can dramatically rise in areas where basic environmental infrastructures are disrupted or have been destroyed. Countries such as Syria, facing complex emergencies and conflict, are thus particularly vulnerable to cholera outbreaks as has been the case in Somalia, Haiti and the Democratic Republic of Congo. For some European politicians, though, the long legacy of epidemic diseases and its preserved impact through cultural imagery has fuelled an increasingly xenophobic discourse around the current refugee crisis, one not based on a scientific understanding of infectious disease risk.

The recent victory of Jaroslaw Kaczyn’s Law and Justice Party, on a vociferously anti-refugee platform in Polish elections, highlights the problem.

In a recent campaign speech he stated: “There are already signs of the emergence of very dangerous diseases which haven’t been seen in Europe for a long time: cholera on Greek islands; dysentery in Vienna; various types of parasites, protozoans, which aren’t dangerous in the organisms of these people but which could be dangerous here.”

His words undermine efforts to develop European policy on the basis of solidarity and a common empathy for those less fortunate.

Mr Kaczyn, in his earnestness to shape future events, perhaps forgets that in the long annals of people movements around the world, Polish refugees too at one point, introduced cholera to Western Europe, following their flight from Russia in 1831.

He forgets also that after their release by Stalin in 1942, as many as 300,000 Polish refugees, were resettled around the Middle East in countries such as Lebanon, Palestine and Iran by the British overlords of the region (the largest numbers came to Iran initially – the Campolu suburb of Tehran derives its name from those Polish refugee camps). Many of the personal accounts from that time report that infections such as typhoid, cholera and dysentery were common among the moving refugees.

In Syria, the large displacement of people to overcrowded camps, where provision of potable water and sanitation is a significant challenge, constitutes a major risk factor for cholera. With the official declaration of cholera outbreaks in neighbouring Iraq in September this year, and a continued degradation of health service and surveillance infrastructure in Syria, the risk of disease contagion and large scale outbreaks occurring are increasing.

As of 27 October the Iraqi health ministry had reported 2055 laboratory confirmed cases of the disease in 15 of 18 governorates in Iraq. In response, the World Health Organisation is organising a mass vaccination campaign targeting 249,319 vulnerable people across 62 refugee camps in the country.

The fact that the initial foci of this outbreak include the religiously significant towns of Najaf and Karbala, where tens of thousands of Shia Muslim pilgrims recently converged to mark the religious events of Ashura, means that concerns of a global spread from isolated cases of returning travellers are real. The risk of cholera spreading to refugee camps in the countries surrounding Syria - Jordan, Lebanon and Turkey - already stretched by the strain of hosting millions of refugees will now also be rising.

Repeated warnings from the United Nations High Commissioner for Refugees (UNHCR) highlight that the emergency response effort is under-resourced. This includes the ability of authorities to provide clean water, safe sanitation and conduct disease surveillance. As of the 20th of October, the UNHCR regional refugee and resilience plan still had a 55 per cent funding gap of over $2.4 billion for 2015 alone.

Significantly, much of the available funding cannot be used to support host communities neighbouring the camps, further compounding the risk of epidemic-prone diseases like cholera spreading. Ultimately, if the cholera risk is not addressed in the camps, surrounding areas and within the conflict zone itself, the risk of onward transmission to Europe will inevitably increase.

In that respect, Europe can do much to address the situation.

Firstly, the refugee crisis must be reframed such that collective global health security and welfare is viewed through the prism of reducing global inequalities, encouraging representative good governance and economic development, and not through the narrow lens of biosecurity and stopping disease transmission across increasingly porous borders.

Secondly, building on its strong institutional networks, from the European Centre for Disease Control and its links to reference laboratories, to individual national public health agencies, a coordinated approach to health needs assessments and surveillance should be developed. Standardised protocols should be applied so that incoming refugees are afforded a dignified welcome and feel safe to register with local health services. They should be empowered to report any symptoms without the fear that they will be separated from family, deported or stigmatised for doing so. This is the best defence against diseases like cholera.

Europe already has strong public water and sanitation systems, excellent health infrastructure, and well-integrated and responsive disease surveillance networks - it is at very low risk from large outbreaks of cholera.

The threat to Europe’s health and wellbeing does not emanate from the contagion of refugees but from within its own moral and social fabric. Generosity, tolerance and respect will ensure the integration of new arrivals and preserve Europe’s well-functioning public health system. Policies peddling isolation, fear and bigotry will erode it.

Dr Osman Dar is a Consultant in International Public Health at Public Health England, and Consultant Research Fellow at the Centre on Global Health Security, Chatham House