Potential Cholera Outbreak in Iraq

Stephen DeAngelis

December 12, 2007

In many post-crisis situations, cholera is a serious problem. The disease causes severe diarrhea, dehydration, and often death. People usually get infected with the cholera bacteria by eating contaminated food or drinking contaminated water. According to Wikipedia, in its most severe forms, cholera can affect an otherwise healthy person within an hour of the onset of symptoms and the victim may die within 2-3 hours if no treatment is provided. More commonly, the disease progresses from the first liquid stool to shock in 4-12 hours, with death following in 18 hours to several days without rehydration treatment. The fact that the United Nations has recently warned of a potential cholera outbreak in Iraq says much about the slow progress of infrastructure rebuilding in that war torn country [“A Microscopic Insurgent,” by Mark D. Drapeau, New York Times, 4 December 2004]. Drapeau is an op-ed contributor and a fellow at the Center for Technology and National Security Policy at the National Defense University in Washington, DC.

In late November 2007, “the United Nations warned of a potential epidemic of deadly cholera in Baghdad, noting that there had been more than 101 cases. This was hardly a surprise: cholera, caused by a bacterium that produces severe diarrhea, broke out in Kirkuk, in northern Iraq, in August and has now spread to at least half of Iraq’s 18 provinces. At least 30,000 Iraqis have displayed cholera-like symptoms and more than 2,500 cases have been confirmed in Kirkuk alone.”

Those of us living in the West hardly think twice about having a case of diarrhea. We pop an Imodium-D and go about our business. We don’t often even have to see a doctor. In places where medicines and healthcare are not widely available, clinics and hospitals can be overwhelmed by epidemics. The best way to treat a cholera outbreak is to prevent it. Prevention is not easy because it requires investment in basic infrastructure like sewage treatment, garbage removal, and clean water systems.

“The threat is bad enough in the overcrowded communities of poor countries, but epidemics thrive in war zones. In dense areas like Baghdad or refugee camps, the Vibrio cholerae bacterium spreads quickly via untreated water or raw sewage. Latrines in these places often adjoin living quarters, making the spread of germs almost inevitable, and mothers commonly scavenge for leftover food to feed children — food that may be mixed with contaminated water or feces. It’s no coincidence that Iraqi areas with the filthiest water and most raw sewage are breeding grounds for both V. cholerae and insurgents. In a perverse feedback loop, insurgents in these places are more likely to become ill, but conditions for the surrounding populace simultaneously deteriorate, increasing support for the insurgency. Another perverse circumstance is that chlorine is often used to treat cholera-infected water, but because insurgents have started using chlorine trucks in bombing attacks, restrictions on chlorine distribution have led to reduced water treatment and possibly increased the prevalence of cholera.”

Talk about your vicious circle! Drapeau notes that war and disease are common traveling companions.

“War and sickness are inextricably intertwined. Large groups of men living at close quarters on scant sleep are perfect carriers. Indeed, microbes have had a larger effect on the outcome of wars than many care to admit, from smallpox outbreaks in the French and Indian War to the pandemic influenza in World War I. As Clausewitz (who died from cholera in 1831) might have said, war is the continuation of disease by other means.”

While the cases Drapeau relates were not deliberately caused epidemics, many in the U.S. fear that biological agents could be used in a terrorist attack. Like most linked cases of conflict and disease, cholera cases spreading across Iraq are a result of the conditions brought about by war. Drapeau underscores the fact that the disease doesn’t take sides (except maybe against the desperately poor) and it can affect military forces as well as civilians.

“In Iraq, of course, it’s not only insurgents and civilians who are at risk of disease. Given the asymmetric nature of conflict, which group do we expect to be more affected by an epidemic: large, centralized conventional military forces or small, agile insurgent units? The answer is that a 10 percent loss within a 5,000-member brigade is far more devastating than losing two members of a 20-man terrorist cell. And suicide bombers don’t call in sick. Disease doesn’t respect borders any more than it does sides in a conflict. Officials in Tehran reported last month that the cholera epidemic had crossed from Iraq into Iran. Syria, Jordan and Kuwait have stepped up border surveillance and disease-detection programs. Saudi Arabia has cited the disease in suspending trade with both Iraq and Iran, and in some cases has banned Muslim pilgrims from entering with food or water.”

Drapeau then asks the obvious question: “What can be done within Iraq to reduce the spread of cholera?” One might also ask who should undertake the mission.

“Despite the general ineffectiveness of the Baghdad government, the Ministry of Health has begun a large cholera-awareness campaign outlining basic procedures for water decontamination. Still, while this is helpful, plastering cities with informative posters and having doses of vaccine on standby is an incomplete strategy. To stop the flow of cholera, the best solution is a clean-water program and better management of waste. The government and the American authorities need to improve sanitation, especially in Baghdad’s slums and in downtrodden rural areas. Epidemics flowing through fragile new democracies are more than a medical problem. Iraq’s leaders need to decide now how they will preserve the continuity of government services in case of an overwhelming outbreak: Is the military prepared to step in if the civil and medical authorities are indisposed? How will security be maintained if army barracks or police stations succumb? Cholera is a grave threat for the American project in Iraq, but also an opportunity to capture the hearts and minds of the population. The average Iraqi will feel truly secure only when the vicious disease-poverty-insurgent feedback loop is snapped. As we plan the post-surge phase of American operations, our leaders must bear in mind that healthy people make healthy decisions that serve as the bedrock for healthy societies.”

In numerous past posts, I have asserted that a healthy population is a necessary pre-condition to development. Development, as we discuss it in our Development-in-a-Box™ approach, is about creating good jobs so that people can rise out of poverty. Employers are not looking to set up shop in areas where the populace is sick. The risks and cost of business in those locations is simply too high. Only a holistic approach to development works. One cannot just focus on health or education or infrastructure or jobs or financial services or transportation or energy; but all of those areas must be dealt with simultaneously because any one of them can undermine efforts in other areas. Health challenges, however, are first among equals because a sick population cannot help tackle challenges in other areas. In the case of cholera, health and infrastructure challenges are inextricably linked.