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As Lebanon struggles amid poor sanitation and collapsing infrastructure exacerbated by the unprecedented and ongoing economic crisis, October 2022 marked the first cholera outbreak in almost three decades. The near epidemic currently being witnessed illustrates the utmost need for adopting a Water-Energy-Food (WEF) nexus approach. The WEF nexus reflects a holistic, socio-ecological system perspective that values all three sectors equally and draws on the synergies among them.
Cholera is gradually tightening its grip, as confirmed cases increase rapidly and continue to spread across the country. Two principle factors have contributed to the recurrence of cholera cases in Lebanon since 1993, when the last case was reported. First, the open, unsupervised borders and influx of refugees, which at times have brought with them undetected diseases. The spread of infectious diseases through migration patterns is affected by and affects interconnected resource systems or mutually utilized resources.
The current outbreak started in Akkar, North Lebanon, following a cholera outbreak in Syria on September 10. Akkar is one of the most underprivileged and vulnerable areas in the country, where access to safe water is limited and socioeconomic conditions prohibit the population from overcoming water shortages by accessing reliable private water sources or purchasing bottled water. Densely populated areas that are also crowded by clusters of refugee camps create an ideal breeding environment for diseases, given poor water sanitation and hygiene practices and lack of adequate wastewater disposal.
The second factor accelerating the cholera outbreak is the near total lack of power supply from national utility Electricite du Liban (EdL). Water establishments in Lebanon usually carry out appropriate water treatment, part of which is chlorination. However, frequent and prolonged electricity blackouts have interrupted or significantly hampered water treatment processes. In parallel, the pre-existing poor infrastructure in many regions that have experienced a cholera outbreak has reduced communities’ resilience and ability to contain this outbreak. Lack of adequate monitoring and maintenance practices, deteriorated networks and proximity of sewage networks and wastewater treatment plants to water supplies have increased the probability of cross contamination. Accordingly, sewage intrusion would create a further hospitable niche for transmission, and threaten water intended for irrigation by providing yet another route for transmission. In this context, food security is also at risk as yields would be reduced due to potential decline in the demand for produce. The reduction in demand for perceived cholera contaminated produce is a reflection of the unpreparedness of communities in terms of the capacity to secure logistics, kits and supplies for disinfection purposes and the lack of awareness on how to carry out proper disinfection of vegetables and fruits.
The current cholera crisis highlights the deep interconnections between the WEF sectors and reflects the intertwined relationship existing in WEF nexus frameworks. In 2021, the WEF Nexus Index ranked Lebanon 156 among countries worldwide. The water index indicated that 90% of people have access to basic safe drinking water, 92.6% use basic drinking water services, while 99.2% benefit from basic sanitation services. However, the re-emergence of a waterborne disease that was eradicated decades ago indicates that Lebanon’s WEF index is declining.
Several international NGOs have responded with an emergency plan to combat the cholera outbreak mainly by supplying vaccines, especially in densely populated areas, and maintaining constant energy supply to operate water and wastewater facilities. However, attention should also be directed towards regulating the influx of refugees and controlling the borders, primarily because of the cholera outbreak that has gone out of hand in Syria.
Above all, policy makers should prioritize having a long-term cholera control and elimination protocol. It is imperative to develop a National Cholera Control and Elimination Plan (NCP) in line with the Global Task Force on Cholera Control’s (GTFCC) Ending Cholera: A Global Roadmap to 2030 and most updated WHO standards. A retrospective assessment is then essential to identify strengths and weaknesses of the current response to help improve preparedness for future outbreaks and guide the development of a national plan. This would empower the government and allow it to reinforce an effective surveillance routine, focus on sustainable improvements in water supply, sanitation, food safety, strengthen healthcare systems and ensure inter-sectoral coordination for proper risk communication and management.
 Global Task Force on Cholera Control: Ending Cholera—A Global Roadmap to 2030 operationalizes the new global strategy for cholera control at the country level and provides a concrete path toward a world in which cholera is no longer a threat to public health. https://www.gtfcc.org/wp-content/uploads/2019/10/gtfcc-ending-cholera-a-global-roadmap-to-2030.pdf