How did Lebanon deal with cholera outbreaks in the past?

How did Lebanon deal with cholera outbreaks in the past?

Beirut's seaside quarantine center as seen from the Land Castle in 1876. (Credit: Louis Vignes via BnF Gallica)

BEIRUT — A rare outbreak of cholera in Lebanon this past week and an ongoing, much larger outbreak in neighboring Syria have raised fears that the illness could further spread as the country’s economic crisis complicates medical access.

News of the most recent outbreak of cholera, a diarrheal disease caused by bacteria from contaminated water and feces, comes as Lebanon reels from the COVID-19 pandemic and an ongoing financial crisis that has hit all sectors of society.

According to the most recent World Health Organization count, the 18 cases so far recorded in Lebanon come after more than 13,000 reported cholera cases and 60 deaths in neighboring Syria since August.

Of course, this isn’t the first time that Lebanon — or its neighbors — have grappled with the disease, once a far more common killer before modern hygiene methods.

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Though the last recorded outbreak in Lebanon was in the 1990s, there is a long history of officially recorded cholera outbreaks as early as the first half of the 1800s, when today’s Lebanon was still under Ottoman rule, and as recently as the Lebanese Civil War, when various militias sometimes prevented clean water and medical supplies from entering blockaded areas.

Notable early cholera outbreaks occurred in what is today Lebanon in 1821 and later in 1831. At the time, Lebanon and Syria were under the control of Mohamad Ali Pasha, a rebellious Ottoman ruler and the de facto leader of Egypt. After his rule came that of his son, Ibrahim Pasha.

The latter entrusted Mahmoud Nami Bey, the chief city engineer of Egypt’s Alexandria, with modernizing Beirut. One of Nami Bey’s main contributions was setting up a quarantine in the 1830s on the outskirts of the old city center of Beirut, in the portside neighborhood known today as Karantina after the site.

Another quarantine was also established inside Horsh Beirut, in the southern part of the city.

The two sites meant that incoming travelers possibly carrying cholera and other diseases would have to isolate either in Karantina if arriving in Beirut by sea, or in Horsh Beirut if arriving by land.

At the time, health authorities enforced a two-week isolation period in the quarantine sites. However, travelogues from the time note that the rules were often skirted.

Quarantined pilgrims stand in front of the Beirut quarantine center's mosque in 1933. (Credit: Ahmed Cherif)

A typical stay would have entailed paying a daily fee for a room and extra payments for fumigation and care from a doctor. Though the quarantine stays were mandatory, a restaurant attached to the Karantina site offered a sense of normalcy, according to a travelogue from the time by Arthur Holroyd, a British politician who traveled through the Middle East in the 1800s.

At first, this was considered a successful intervention, Diala Lteif, a postdoctoral researcher at the University of Cambridge who has studied Karantina, told L’Orient Today. She said that the cholera outbreaks in the 1800s were “very disruptive for businesses and trade, and so officials had to find ways to protect everyone’s interests.”

The added protection, Lteif said, made the port more productive and sustainable in the long term. But she noted that the quarantine site there was not designed to take in huge numbers of travelers, which eventually made it less effective. And by the 1840s and 1850s, as the city grew, the overcrowded quarantine site started helping to spread more diseases than it prevented.

According to historian Jens Hanssen in his book Fin de Siecle Beirut, the city recorded its worst outbreak of cholera yet in 1865 with around 3,000 deaths — mainly working-class people who could not manage to leave Beirut for relative safety. Meanwhile, the city’s more privileged residents were able to escape to rural parts of Mount Lebanon.

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American missionary Henry Jessup, one of the many founders of the Syrian Protestant College (later the American University of Beirut) in the 1860s, lent a firsthand account of the outbreak in his memoir: “Not less than twenty thousand people left the city in a week … old and young, mounted and walking, faces pale with fright, and all this before there had been a single case in Beirut; but after a few days the disease broke out.”

This, he added, “broke up our congregation, the press work and the building [of the college campus] as the workmen had all left the city.”

Because so many residents had fled Beirut to the mountains, many villages set up their own makeshift quarantines for newcomers, where they’d remain in isolation for 15 days.

However, those fortunate enough to leave Beirut during the cholera outbreak later returned to the city to find that their homes had been looted, Jessup recounted in his memoir.

Many outbreaks of disease at the time could be blamed on Beirut’s newfound status as a regional trade hub, as merchants and pilgrims began streaming into the city.

A postcard showing the Beirut quarantine center from the sea in 1907. (Courtesy of the Sami Toubia collection)

A hub for travelers — and the spread of disease

After the deadly 1860s outbreak, cholera would turn up again, albeit on a smaller scale, in 1875 and 1882.

In the 1890s, a French medical consultant named Benoit Boyer was hired by Ottoman officials to write a report evaluating medical conditions and public hygiene in the city.

His report expressed grave concern. Most importantly, Boyer asked, how effective could Beirut be at combating cholera with its now decades-old quarantine facility in Karantina sittings in disarray?

Boyer and others feared that the city could be a gateway for cholera to the rest of world because of Beirut's bustling seaport and its strategic location. They worried that a newly built railway bringing in people from nearby cities could also drive up case counts, especially since the train station was just steps away from the quarantine center.

One of Boyer’s suggestions was to gut the city, which he saw as cramped and susceptible to the spread of disease, and rebuild major portions of it from scratch. According to Hanssen in his book Fin de Siecle Beirut, the idea turned into a guiding vision for planning discourse in the city, first implemented during World War I.

During the French mandate period after World War I, Beirut’s seaside quarantine station was expanded to include new accommodations as well as testing facilities to prevent cholera outbreaks among Hajj pilgrims transiting through Beirut to Mecca, according to French historian Luc Chantre. French officials in charge of the quarantine center even built a mosque on the premises to deter travelers from breaking their isolation period.

The Hajj pilgrims first had to quarantine in Beirut for medical testing and vaccination. Before departing by sea to Jeddah through the Suez Canal, passengers would receive a vaccine passport. Some 150,000 cholera vaccinations were administered in 1931 alone, according to Chantre. This helped stem the spread of the disease — both in Mecca 1,500 kilometers away and in the pilgrims’ home countries.

Wartime illness

The arrival of widely available antibiotics in the first half of the 20th century, however, didn’t permanently eradicate cholera from Lebanon.

That is due, in large part, to the country’s 15-year civil war, which lasted from 1975 to 1990 and allowed for the illness to resurface in some areas due to worsening public health conditions.

One cholera outbreak in a besieged part of Tripoli, in Sept. 1976, left five people dead, the International Committee of the Red Cross (ICRC) told news media at the time.

Then in 1985, blockaded Palestinians in the Shatila refugee camp in Beirut suffered an even deadlier outbreak, with 12 children dying of cholera, the Associated Press reported. The spread of the illness was worsened by the blockade itself, when the so-called War of the Camps at the time between Amal, the Palestine Liberation Organization (PLO), Hezbollah, the Communist Party and Walid Joumblatt’s Progressive Socialist Party (PSP) cut off access to clean water and medicine.

Another 15 people died of cholera in Tripoli in 1990 due to medicine, electricity and water shortages, Reuters reported at the time.

And finally, according to Lebanon’s Ministry of Public Health, the last cholera outbreak in the country occurred in 1993.

So how worried should people in Lebanon be amid today’s cholera outbreak — particularly as the country’s economic crisis harms the medical sector?

“Cholera doesn’t kill like it used to in the 19th and 20th centuries,” Anis Germany, a Lebanese doctor and public health researcher told L’Orient Today.

What is worrying, however, is what the current outbreak reflects about the “state of the Lebanese healthcare system” amid the country’s economic crisis, Germany added. “The outbreak of such infectious diseases that are not endemic to our country and [that] are prevented with good sanitation and public health measures signifies that the whole system is falling apart.”

Such measures, he said, “fell apart once healthcare became inaccessible to the majority of the population.” 

BEIRUT — A rare outbreak of cholera in Lebanon this past week and an ongoing, much larger outbreak in neighboring Syria have raised fears that the illness could further spread as the country’s economic crisis complicates medical access. News of the most recent outbreak of cholera, a diarrheal disease caused by bacteria from contaminated water and feces, comes as Lebanon reels from the...