By Anna Foster
BBC News, Beirut
Mohamad Akel can’t breathe. He heaves over onto his side, retching, and begs for the water he isn’t allowed to drink.
He arrived at the hospital emergency ward from his home in Minyel just a few hours ago. The doctor suspects cholera.
“All my body aches, I have fever and chills,” he groans. “Now I really can’t take anything in. If I did it would go out again from here and here.” He gestures first to his mouth, and then further down.
He hasn’t got time for this. Mohamad is a farmer, and needs to be out working in his fields. He coughs again, rolling from side to side on the bed in pain. But he’s determined to tell me who he blames.
“There is a Nobel prize for peace? Lebanon deserves the Nobel prize for failure. All of our politicians are corrupt. It’s no surprise we got to this situation.”
The country’s political failures are tightly woven into this outbreak.
Despite elections in May, no new government has been formed. The national electricity grid provides just an hour of power a day, if that. The currency has lost around 90% of its value, and medicines can be hard to find. More than 80% of the population here is living in poverty.
Lebanon has collapsed from a reasonably affluent country into one at risk from the chaos that a preventable, treatable disease like cholera can cause.
It’s transmitted through unclean water, and in a place where the most basic sanitation systems have broken down, the spread can be rapid.
The last Lebanese cholera case was three decades ago. It returned on 6 October. There’ve been hundreds of suspected cases since then, but because there aren’t simple diagnostic tests the true figure could be thousands.
Now Lebanon is one of 29 countries to have reported outbreaks since January of this year.
Neighbouring Syria is already dealing with thousands of cases, and Afghanistan, Pakistan and Haiti are among those affected.
In the last five years fewer than 20 countries on average have reported cases, and the World Health Organisation has called 2022’s rise in infections “unprecedented”.
It’s even had to suspend its two-dose cholera vaccine strategy because of a shortage in the global supply.
Cost of care
As I walk from room to room on the children’s floor of the Abdallah Elrassi hospital, the patients keep getting younger.
Ziad Al Ali is five. He lies quietly, his brown eyes gazing at the ceiling.
Mira Sofan, a Syrian refugee, is 18 months old. Her drip needs replacing, but she’s crying and thrashing as her mother tries to soothe her.
Jad Hussam Al Jundi was born just four months ago, and his sleeping body is a small dot on the expanse of white hospital bed. His proud new parents have brought him all the way here from Tripoli, nearly an hour away. They couldn’t find treatment any closer to home.
The sound here is unlike a normal hospital ward. The silence isn’t punctuated with the usual beeping and whirring of sophisticated machines. Each child has little more than a bag of intravenous fluid hanging quietly by the bed.
With the right care cholera is easily treatable. But the response has to be fast.
One Lebanese man was desperate to tell me about the difficulties he faced getting treatment for his daughter.
“They wouldn’t take her unless we paid two million Lebanese lira [$50 according to the black market rate]. What should we do? Steal? Kill? We don’t carry arms. We are poor”.
The Lebanese government has now agreed to cover the medical costs for its citizens who contract cholera.
But for the country’s around one million refugees – it’s hard to know exactly how many live here – the situation is less clear-cut.
The UN refugee agency UNHCR provides for their medical care, but many Syrians fear having to pay for it themselves.
Sometimes it means they avoid going to hospital until the last minute. For a disease that moves as swiftly as cholera, that delay can be deadly.
River of brown water
The Abdallah Elrassi hospital is the only public hospital in Akkar, in Lebanon’s north. This is the poorest part of the country. The hospital’s Director, Dr Mohamad Khodreen, fears they could be overwhelmed by the growing outbreak.
“We have now dedicated 70% of our beds to cholera cases,” he says.
“And after the Health Minister Firass Abiad visited here he asked us to provide even more. Soon we’ll have around 120 beds. But this is a small hospital for a big area, and cases are increasing. If the problem isn’t contained, we won’t be able to cope”.
Most parts of the country have now recorded cholera cases, and it’s also been detected in the wastewater in the capital, Beirut.
Bebnine in the north has seen one of the biggest cholera outbreaks in Lebanon so far.
A man-made channel of brown water cuts right through the heart of the town. It’s completely opaque, and looking into it you can’t see even a hint of what lies below the surface.
Houses perch right next to the water’s edge as it flows lazily downstream. One of them is home to Hussein Ali.
His brother, Hasan, died from cholera three days before we meet. His wife, niece and nephew are all being treated too.
“We don’t know where we got infected from” he says. “Is it the air or the water? We are living in a state of panic, we are afraid of everything now.”
His grief is still raw, and he wipes his face with his hand.
“I lost the most valuable person I had. He was my soulmate, my wingman. He was my friend all day long, we only separated at night to sleep.”
Normally when there’s a death, members of the community flock to pay their condolences. Average numbers can reach 1,000. But outside Hussein’s home the brown plastic chairs remain stacked, and a tray of welcoming dates is almost untouched.
Hardly anybody visited the family, because they’re too scared of catching cholera themselves.
The river of brown water often ends up being used to irrigate crops, and it’s making the spread of cholera worse.
Homes have visible pipes leading up from the channel to bring water indoors, and others that hang out over it discharging household waste back in.
Umm Ahmad, her husband and children live on a smallholding, and have to grow produce for their landlord as part of their rent agreement.
In a few days they’ll be digging fresh shoots into the brown earth beneath the polytunnels. She knows that there’s a strong chance the pipes that water them will bring cholera from the stream.
But she tells me they have no choice.
“Of course I’m worried,” she frowns. “My brother caught cholera and a number of our neighbours have died from it, including a young man just today. We try to avoid it but we don’t always have a choice.”
Ettie Higgins, the Deputy Representative in Lebanon of the UN children’s agency UNICEF, says they’d been warning of a cholera outbreak for more than a year.
There were dangerous markers suggesting that if it transferred across from Syria, the dire conditions here would only aid its spread.
One big problem was the breakdown of Tripoli’s wastewater treatment plant – another casualty of Lebanon’s electricity crisis. It would normally deal with everything from human faeces to industrial waste from factories and slaughterhouses. But now there’s nowhere for it to go.
“Normally this waste goes through an initial screening,” Ms Higgins explains, “and it gets pumped out 1,600 metres [5,250 ft] into the sea. But because of the lack of fuel, they were unable to even pump it out to sea. So it was just being deposited directly onto the shoreline instead.”
Cholera cases in Lebanon are still growing by the day, and the problems causing it are so numerous that they’re a huge challenge to fix.
But until there are real, tangible improvements to the country’s infrastructure, it’s hard to see how this outbreak can be brought under control.